EL NIPLITO DEL SURESTE

Dear Ms***This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated that she had questions concerning the response from her previous complaintShe was told she only owes $120.48, but the online invoices show she owes a total of $484.48.Highmark has updated the member’s invoicesHer most current invoice generated on June 9, It has a current balance due of $There is also a total balance of $due by June 27, This includes the current balance and June and July’s premium paymentsThis invoice will not be viewable until the next bill cycle runsThe member can contact Highmark Customer Service to make a payment.If you have additional questions, please contact me directly.Sincerely,Michelle D***Appeals CoordinatorPhone: ***

Revdex.comAttn: *** *** *** *** *** *** ** ***Case ID:***File Number: ***Dear Ms***;This is in response to your inquiry sent to us on behalf of the member identified by the Case ID number noted above.The member states that she was
covered through Blue Cross: Blue Shield of Northeastern Pennsylvania (NEPA) beginning in July She states that when the plan changed to Highmark in 2016, she began to have problems with the billing and had to call each month to make her paymentsShe states that this was an ongoing problem for six monthsThe member states that in June 2016, she had some family issues and forgot to make the paymentOn July 22, 2016, she called Highmark Customer Service, and her payment was taken.The member further states that she would call each month to make her payment, and when she would try to pick up her prescriptions, the pharmacy would tell her they denied because she did not have active coverageShe would then call Highmark Customer Service and conference calls would be placed to the Federally Facilitated Marketplace (FT’M), resulting in being told her coverage was active, until the next month when she states this would happen again.In December 2016, the member stated that she was advised by Highmark that her policy was cancelled effective June 1, 2016, and she would be receiving a refund of payments that had been made since then; however, she states that she has not received the refundThe member also stated that due to the cancellation of her policy, she is now subject to a fine by the IRS for the months she was uninsured.The member is requesting that she be sent the refund she was promised, that the denied claim for services rendered in September be paid, and that Highmark provide her with a letter stating Highmark is at fault, and that due to Highmark’s mistake she cannot be held liable for the penalty for being uninsured.Highmark has reviewed the member’s account, including the enrollment files received from the FFM, her invoice and payment history, as well as the associated telephone calls to Highmark Customer ServiceHighmark received an enrollment file from the FFM on December 3, 2015, enrolling the member into the My Blue Access policy effective January 1, 2016, The initial application had a Total Premium of $136,On January 2016, a new enrollment file was received which corrected the Total Premium to $effective February 1, 2017.Highmark sent the initial invoice on December 2015, for the January coverage periodThis payment was due by January 1,The payment was received on January 22,,2016, along with the payment for February, Because of the merger between Highmark and NEPA in January 2016, members in that coverage area were given the additional time to make their binder payments because the automatic payment schedules did not transfer into Highmark’s systemThese members were advised to go onto Highmark’s website to re-enroll for their recurring payments.Invoices for March, April, and May generated on February 8, March 8, and April 8,2016, Because the member did not receive an Advance Premium Tax Credit (APTC), her policy had a 31-day grace period from the paid to date in which to pay the premium to avoid termination of coverage, On April 19,2016, she called Highmark and advised she tried to log into the website, and only her previous year’s policy showedShe asked to make her payment by phoneThe Customer Service Advocate (CSA) she spoke to advised her that because she was past the 31-day grace period, her payment could not be takenThe member requested a supervisor, but while on hold for a supervisor, she disconnected the callShe called back in and spoke to a different CSA, who took her payment in the amount of $The payment was taken because she was not sent the required delinquency letterThe payment brought her current to June 1, 2016.The invoice for the June coverage period was generated on May 8, 2016, with a due date of June 1, The invoice for July was generated on June 8, 2016, showing the past due premium for June, as well as a notice stating the entire balance was due no later than the due date on the invoice to avoid termination of coverageA delinquency letter was mailed on June 8, 2016, stating that payment to bring the account current must be received no later than July 4, 2016, or the policy would be terminated,On July 7, 2016, the policy was cancelled for non-payment effective June 1, 2016, and a cancellation notice was mailed to the member on July 8, 2016.The member called Highmark on July 22, and requested to make a paymentThe CSA advised her that the policy was cancelled due to non-payment because the payment was not received within the -day grace periodShe stated that she did not receive the delinquency letter because she was in the process of movingThe CSA advised that she would have the account reviewed for a possible reinstatementThe reinstatement was denied because there was no billing error, and a delinquency letter was sentThe member had never contacted Highmark to report a new mailing address.On August 2, 2016, she was advised the reinstatement was deniedThe CS A placed a conference call to the FFM with the memberThe FFM representative advised that the application would be reopened, and the member would be active August 1, 2016.Highmark received a new enrollment file from the FFM on August 3, Instead of a lapse in coverage and a new effective date, this file reflected active coverage through August 31, A second file was received the same day which showed coverage starting again September 1, Because these files from the FFM show no lapse in her coverage, she was invoiced on August 10, 2016, for the September coverage period, and the months of June, July, and August were billed as wellThis invoice reflected a total balance due of $521.16, with a due date of September 1, 2016.On September 6, 2016, the member contacted Highmark due to the invoice balanceShe stated that she was told that her policy would be effective September 1,2016, and she would not have to pay the three previous monthsWhen the CSA explained that the enrollment file was sent to show no lapse in coverage, and that is why she was billed that amount, the member requested a supervisor.During the call with the supervisor, she requested another conference call to the FFM, The supervisor placed the conference call and the FFM representative stated that he would escalate a case to be reviewedHe advised that he thought there should just be a new effective date of September 1, The case was received through the Health Insurance Casework System (HICS) on September 7, This case directed Highmark to reconcile oux records to match the application from the FFMHighmark completed a review of the enrollment files, and was unable to change the enrollment, because the files from the FFM show no lapse on her coverageA letter was mailed to the member on September 7,2016, advising that her coverage was effective January 1, 2016, and if she feels the records are incorrect she would need to file an appeal with the FFM.The member called Highmark on October 27, 2016, to make a payment of $The CSA advised her that the coverage was cancelled for non-payment effective to June 1, 2016, because she had not paid currentShe requested another conference call to the FFM because she said she was told she wouldn t have to pay a past balanceThe CSA placed a conference call with the member to the FFMThe FFM representative said they show her with active enrollment, so the CSA took her payment for $The FFM advised of active coverage, because their system had not updated for the cancellation for non-payment.On December 8, 2016, she was advised of the cancellation again, and that a refund was sent in the amount of $on November 7, She was also advised that another refund was to be sent because there was still $in the account as a creditThis refund was sent on December 15, Because neither of these checks have been cashed, and still show outstanding in the system, Highmark has requested a stop payment and reissued a refund check in the amount of $This refund check was sent on January 27, 2017, with express deliveryPer UPS delivery notification, the package was delivered on January 30, 2017.Unfortunately, Highmark cannot change the effective dates of coverage without a corresponding enrollment file from the FFMBecause the enrollment files received do not reflect the lapse in coverage, Highmark’s records are required to match thoseEducation has been sent for the CSAs who took her payments in error.On behalf of Highmark, I apologize for any anxiety or inconvenience this issue may have causedIf you have additional questions, please contact me directly.Sincerely, Michelle D***Executive/Legislative InquiriesPhone: ***

October 19,2015Revdex.comAttn: *** *** *** *** *** ***
*** ** ***Case ID: ***File Number: ***Dear *** ***:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.In his complaint, the
member states that his policy has been cancelled in error at least three times by Highmark after he made his monthly paymentsHe states that he has called Highmark numerous times for resolution, and to have denied claims reprocessedThe member also states that he has had to call Highmark to have an override placed on the prescription portion of the policy due to denials at the pharmacy.I have reviewed the member’s accountDue to a systemic error, the member’s invoice for the April coverage period was generated without the Advance Premium Tax Credit (APTC)This error caused the account to cancel in errorWhen the policy was reinstated, the correction was not updated within the billing system causing an incorrect past due balance to be reflected on the invoicesI have initiated the correct adjustment with the billing departmentThe invoice for the November coverage period has generated with the correct balance of $to pay the account to December 1, 2015.If you have additional questions, please contact me directly. Linda S*Appeals CoordinatorPhone:***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.If you log into my account on the website, you will see my first invoice for this year was for March! If my coverage was effective since January, then explain that?Also on the site, when you pull up my invoices, or go to "Pay Monthly Premium," it still says I owe $484.48! Why does it say that if I only owe $120.48?
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.I have called and complained about the horrible
customer services I have received especially from the Supervisor ConnieI
called in last week and spoke w/ Connie and she was so rude and placed me on
hold and passed me on to someone elseI asked for the manager Stephanie to
contacted me they advised she was sick but will call me Monday and have yet to
receive a callI spoke w/ Stephanie a month ago in regards to the horrible
issueShe stated she will be contact with me and wait to the claims have been
paid and that was not true I ended calling her no responds backI called
customer services and was advised that I am a month beyond which is not correct
because the letter they sent me on in Aug states $is due in order for the
acct to be active which I paid and they stated I was billed in advance and they
don't know whySo its showing a month beyond.For this to be corrected when I spoke w/
Stephanie I don’t recall her stating I was billed in advance and the letter
tell me how much I would pay a month for my son *** *** ***(minor
chip program) did not say you will be billed in advance
Regards,
*** ***

June 6, 2016Revdex.comAttn: *** *** *** *** *** *** ** ***Case ID: ***File Number: ***Dear Ms***:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.In her complaint, the member
states that she received notification from Highmark on May 20, 2016, advising her that her policy was cancelled effective March 1, 2016, but that Highmark had cashed her premium cheeks for her April and May premium paymentsShe states that when she contacted Highmark she was advised that the policy cancelled because she still had a balance of $166,for the month of MarchThe member further states that she had the same problem last year and was cancelled due to an error within Highmark’s system.Upon reviewing the member’s account, Highmark has determined that the member was invoiced correctly since February 2015, The invoice generated on December 8, for the January enrollment period reflected the same Advance Premium Tax Credit (APTC) that the member had in This was due to not receiving her updated information from tire MarketplaceThe new enrollment information was received from the FFM on December 17, 2014, and the February invoice was generated reflecting the adjustment to the APTC for January.Effective May 1, 2015, the member’s APTC was updated by the FFM and this new information was sent to HighmarkThe change to the APTC resulted in a decrease of $per month to her monthly premiumAlthough she was invoiced with the lower premium, she continued to send the original payment amount, which resulted in a credit to her account each monthIn October 2015, the member contacted Highmark Customer Service and was advised that the credit amount on her invoice was correctThe member requested that the overpayment be refunded to her rather than keeping it on the account.After this refund was issued, the invoice for the December coverage period was generated on November 9, This invoice correctly reflected a balance of $Effective January 1, 2016, the member no longer received an APTCThere was a premium increase for 2016, and without the APTC, she is now responsible for the full premium amount of $per month.No payment was received from September 14, Until January 21, The payment in September was part of the refund issuedThe payments the member sent starting January 21, 2016, were not enough to satisfy the balance dueBecause the member no longer receives an APTC, her policy has a thirty-one day grace period from her paid to date to pay the premium, or the policy will cancel for non-paymentBecause the balance remaining for the March premium was not received within this grace period, the policy was terminated for non-paymentHighmark reinstated her policy because she did not receive a delinquency letter advising her of this.At this time, the member has been advised that she has a total balance due of $to pay the account through July This payment is due by June 30, A detailed payment and invoice history is available to the member upon her request.If you have additional questions, please contact me directly.Linda S*Executive/Legislative InquiriesPhone: ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me The follow up call I received after I submitted the complaint resolved all of my issues Thank you
Regards,
*** ***

Dear Ms***:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated in her complaint that she has attached two documents with her complaint regarding her claim from date of service July 24, The first document shows how her original claim processed and shows she owes nothingShe stated that for some unknown reason her claim was reprocessedThe member stated that the second document shows the claim after it was reprocessed with a responsible amount of $She stated that after nine months a claim cannot be reprocessed for no apparent reasonShe stated that she has spoken to several people at Highmark that assured her she does not owe anythingThe member stated the reason she was told she owes nothing is because that is what Highmark’s system showedThe member stated for these reasons she is disputing the charge.All of the member’s calls to Highmark regarding this claim have been reviewedAt no time was the member advised that the claim would pay at percent of the plan allowance, with no member responsibilityOn September 14, 2015, the member was advised to have her provider resubmit the claim because there were some coding errorsShe called Highmark on November 9, 2015, and she was advised that the claim had been resubmitted but the coding was still not correctThe Customer Service Advocate (CSA) called the provider’s office and advised them the coding was still incorrectThe provider stated they would have the coding correctedOn March 10, 2016, the member called Highmark and she was advised that the resubmitted claim had been denied as a duplicateThe CSA contacted the provider and advised that they needed to have the original claim voided, so the corrected claim could be reprocessedOn April 22, 2016, the member called Highmark and she was advised that the claim had reprocessed correctlyShe was advised that she was responsible for $The member had a copay of $and $was applied to the member’s deductible.Any service or procedure that is performed by a provider is billed using a procedure code (CPT, or Current Procedural Terminology)Each CPT code is assigned to a specific benefit category for claims adjudication and member cost sharingThe American Medical Association is the source of CPT codes, as well as the categorical classificationThe CPT codes billed on the claim in question are *** *** *** *** *** *** *** *** *** *** ***All of these CPT codes are in the diagnostic benefit categoryTherefore, these procedures cannot be processed as routine, and will not be covered at percent of the plan allowanceThey have been reprocessed correctly according to the member’s benefits.Highmark has reviewed the claim in question per the member’s request numerous timesThe claim was originally sent in with coding errorsIt did not have any routine diagnosis codes listed on itThere were only diagnostic diagnosis codes on the claimWhen the claim was resubmitted all of the diagnostic diagnosis codes were removed and a routine diagnosis code addedHowever, this was still incorrect because not all of the CPT codes were considered routineThe third time the provider submitted the claim it was coded correctly with both routine and diagnostic diagnosis codes, but the claim denied as a duplicateThe provider then requested the claim be reprocessedThe member has been advised the claim processed correctlyWe understand the member’s confusion, and understand this is not the resolution desired and regret that we are unable to come to a mutually agreeable outcome regarding this issue.If you have additional questions, please contact me directly.Sincerely,Michelle D*** Appeals CoordinatorPhone: ***

Revdex.comAttn: *** *** *** *** *** *** ** ***Case ID: ***File Number: ***Dear *** ***:This is in response to your inquiry sent to us on behalf of the member identified by the Case ID number noted above.The member stated in her complaint
that she received notification on December 18, 2015, advising that her health insurance policy was terminated effective October 1, She stated she did not receive any other notification regarding the termination of her planThe member stated she has continued to make payments and has also made a payment on her plan that is effective January 1, The member stated she received medical care and has several outstanding bills due to the termination of her health insurance.According to Highmark’s records, the member entered delinquency July 1, 2015, because the premium payment for July was not received until August 6, Because the member has an Advanced Premium Tax Credit, there is a day non-revolving grace periodWhen she entered the grace period on July 1, 2015, she had days (or until October 1, 2015) to pay the total due on the accountBecause the total amount due was not received by October 1, 2015, the policy was terminated.Delinquency letters were mailed to the member on June 15, August 28, September 23, and November 19, However, due to a systems error, the last delinquency letter was generated when the member had already been canceledBecause of the inconsistency with the delinquency letters, Highmark has reinstated the member.No payment was received in July The payment the member made for her new policy that is effective January 1, 2015, has been applied to her current planBecause the premium amount is higher for than 2015, the member has a $credit that will be moved to her new billing accountShe has a balance due of $352.45, due by January 1, 2016.Any claims that denied because of the termination of the member’s plan will be reprocessed according to her benefitsThe member can expect to receive updated Explanations of Benefits in approximately four to five weeks.If you have additional questions, please contact me directly.Sincerely,Cassandra MAppeals CoordinatorPhone:***

August 15, 2016Revdex.com*** *** *** *** *** ** ***Attention; *** ***File Number: ***Dear Ms***;This is in response to your inquiry sent to us on behalf of our member identified by your ID number ***.Our records indicate the member contacted
Customer Service on July 5, 2016, with concerns about his Health Savings Account (HSA)Our Advocate advised the member his account was suspended due to not receiving the required verification for a reimbursement request for $he had previously submitted; however, the member advised the Advocate he had sent the requested informationIt was determined that although we had received the information the member had forwarded, we were unable to automatically match it to the requested reimbursement amount because the submitted information indicated other amounts than the requested Samount.At the time of this call, the member’s previously submitted documentation was reviewed and it was determined that one of the amounts listed indicated the required $verificationOn July 13, the member was notified the $had been cleared off and his debit card had been reactivated.Highmark would like to apologize for the inconvenience and frustration our member experienced prior to his debit card being reactivated.If our member has any questions concerning his coverage, please have him contact our Customer Service Department at ***, If you have additional questions, please contact me directly,Sincerely,Margie L***Executive/Legislative Inquiries

January 19, 2016Revdex.comAttn: *** *** *** *** *** *** ** ***Case ID: ***File Number: ***Dear *** ***:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.In her complaint, the
member states that she applied for health insurance through the Federally Facilitated Marketplace (FFM) in November for the benefit yearShe states that she had Highmark coverage for her plan, and had no problems with that accountThe member states that she contacted Highmark in late December to pay her premium for the January coverage period because she had not received her invoiceShe states that the representative she spoke to advised her that Highmark was very behind in billing, but that her coverage would still begin on January 1, 2016, and to wait until she receives her invoice before calling back to payThe member further states that she contacted Highmark again on January 7, 2016, because she had still not received her invoice, and was advised by a supervisor that her policy would be cancelled for non-payment of the Binder PaymentShe states that the supervisor confirmed she was given incorrect information, but that the payment could still not be taken, and that there was nothing that could be done.Upon review of the account, Highmark has kept the member’s policy activeWhen she called Highmark Customer Service on December 22, 2015, and questioned how to make her payment for the January coverage period, the Customer Service Advocate (CSA) did not advise her that her invoice had generated on December 4, The member should have been given the option to make her payment over the phone at that time, or been advised how to send her payment without the invoiceBecause this information was not provided at the time of that call, and she was given misinformation about the billing of her policy, she was contacted via telephone on January 7, 2015, and the premium payment for the January coverage period was takenThe member’s policy is paid to February 1, The telephone call from December 22, 2015, has been sent to management for education and coaching.If you have additional questions, please contact me directly.Sincerely,Linda S*Appeals CoordinatorPhone: ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
The level of incompetence displayed at every level by Highmark and their CSA's is staggering There was no explanation given as to why I have in my posession a paper that shows the original claim processed to show I owe nothing and another paper showing that they adjusted my original claim to show I owe $55.75 You people need an entire overhaul of your billing department. I was told originally by your uninformed staff that I would owe nothing for blood work done for a routine, yearly wellness check up And repeatedly told I was billed in error and they would correct it and I should disregard the billsWhere was everyone to tell me then, as they are stating now, that I owe the $50.00??? I believe it is time I start sharing my story on social media so other people don't make the mistake of using Highmark as their insurance carrier I therefore am still disputing this charge
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me.
Regards,
*** ***

This letter is in response to your inquiry sent to us on June 22, 2017, on behalf of the memberidentified by Case ID [redacted].Our records indicate the member is enrolled in a Health Maintenance Organization (I-flvIO)through an employer group. This Grandfathered group is fully-insured and provides a...

three-levelappeal process.Network providers are obligated to submit claims on behalf of their patients. Out-of-networkproviders do not have an agreement with the plan to submit claims for services provided.However, many out-of-network providers will submit claims as a courtesy to their patients.As explained in the benefit booklet, in the event a provider refuses to file a claim, an itemizedbill is required along with a completed claim form to have services considered. A completedstandardized 1SOOS form should contain the necessary information. If that is not available, anacceptable itemized bill includes the following.• The name and address of the service or pharmacy provider. For a professional provider,if their National Provider Identifier (NPI) is not given, the billing should include theirprofessional status (MD, LSW, RN, etc.), and state license number• The patient’s full name• The complete date of the service, supply or purchase (month/day/year) and the locationof the service (office, hospital, home, etc.)• For professional claims, the current procedural terminology (CPT) code of the serviceprovided, or a detailed description of the service or medication/supply. The CPT listingof descriptive terms/identifying codes for reporting medical services/procedures wasdeveloped and is maintained by the American Medical Association (AMA)• The amount charged per service• For a medical service, the diagnosis/nature of illness. This can be a narrative format or codefrom the International Classification of Diseases Clinical Modification Reference (LCD-b)• For durable medical equipment, the doctor’s certification of medical necessity• For ambulance services, the total mileage, and starting/ending locations (home tohospital, hospital to skilled nursing facility, etc.)• Drug and medicine bills must show the prescription name, national drug code (NDC)number and the prescribing provider’s name.Keep in mind, cancelled checks, cash register receipts or personal itemizations are not acceptableas itemized bills. Also, if the claim was filed to another health insurance policy first, and thecurrent claim submission is for secondary benefits, it must include the explanation of benefitsstatement showing payment or denial made by the primary carrier.The previous billing statements submitted for March and April 2017, were itemized andconsidered for benefits. Those received recently for April and May were not. Billing statementsfor ongoing services must contain the required isd’ormation on each bill submitted. We areunable to utilize information from a previously submitted billing statement submitted to facilitateprocessing of a subsequent billing statement that is incomplete.The member also expressed dissatisfaction with the amount of time for claims processing. ThePrompt Payment Provision of Act 62, as mandated by the Pennsylvania State Legislatureprovides for prompt payment of clean claims within forty-five (45) days of the insurer’s receiptof the claim. A clean claim is defined as “a claim for a payment for a health care service whichhas no defect or impropriety. A defect or impropriety shall include lack of required sustainingdocumentation or a particular circumstance requiring special treatment which prevents timeLypayment from being made on the claim.” The claim received April 12, 2017, for the March andApril services was finalized within the required forty-five (45) day period on May 17, 2011.If the member has additional questions, their designated service area is most qualified to assistthem. Knowledgeable service representatives are available at the number listed on theiridentification card.Sincerely,Ms. M[redacted]Regulatory/Legislative Inquiries

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me IF the invoices are generated correctly and at the correct amount as noted on my healthcare.gov agreement.Thanks to [redacted] in W VA for sleuthing out the problem and to all who have addressed it for a resolution.  
Regards,
[redacted]

March 17, 2017Revdex.comAttn: [redacted]Case ID: [redacted]File Number: [redacted]Dear Ms. [redacted]:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated in her...

complaint that in December 2016, she contacted Highmark to find out if a Magnetic Resonance Imaging (MRI) of the [redacted] would be covered. She spoke to two different Customer Service Advocates (CSA) on two different days. Both of the CSAs told her that if she went to [redacted] Hospital to have the MRI done she would not have to pay anything. On December 27, 2016, she had the MRI done at [redacted] Hospital, and afterwards she received a bill for the MRI in the amount of $3,848.90. She contacted Highmark, arid the CSA advised her that she would listen to her calls from December, and if she was told that the MRI would be covered at 100 percent, Highmark would reprocess the claim. The member stated that now every time she calls Highmark they advise that they are still waiting on the proper department to listen to the call. This has been going on for over a month now, and she is worried that her bill will soon be overdue. The member would like for Highmark to pay for the MRI that Was performed at [redacted] Hospital in the amount of $3,848.90, because she was misinformed by a Highmark CSA.Highmark thoroughly reviewed the calls made by the member to Highmark Customer Service in December 2016. On December 6,2016, the member called Highmark Customer Service and asked the CSA if a routine mammogram and MRI of the [redacted] would be covered. The CSA advised that as long as the mammogram is routine it would be covered at 100 percent and the MRI would apply towards her deductible. The CSA also advised her to get the procedure and diagnosis codes, and call back to verify it would be covered. On December 13, 2016, she called with procedure code [redacted] and diagnosis code [redacted] to verify if the MRI would be covered. The CSA advised that was a covered code and would be covered per her benefits.On December 21, 2016, the member called again to verify if there would be a copay for the MRI of her [redacted]. The CSA advised that it would be covered with no copay and she would not have to pay anything because it was fully covered. This information was not correct and staff education will be provided to the CSA who misadvised the member. Highmark has reprocessed the member’s claim for the MRI of the [redacted] showing no member responsibility. She will receive a new Explanation of Benefits (EOB) once the claim has been finalized.On behalf of Highmark, I apologize for any anxiety or inconvenience this issue may have caused the member. If you have additional questions, please contact me directly.Sincerely,Michelle D[redacted]Executive/Legislative InquiriesPhone:[redacted]

Revdex.comAttn: [redacted]Case ID: [redacted]File Number: [redacted]Dear [redacted]:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.In his complaint, the member states that...

he had made a premium payment in the amount of $302.45 at the end of June, for the July coverage period. He states that he was advised by Highmark that the payment was never received and that his policy was in danger of cancelling. The member would like assurance that the payment has been applied to his policy.I have reviewed the member’s account and have located the payment he made on June 25, 2015, via telephone. There was an error in the processing of the payment, and it was not posted to his policy. The payment has been posted, and the member is now paid to August 1, 2015.There was also a discrepancy in the amount he was being invoiced. The member is eligible for an Advance Premium Tax Credit (APTC) in the amount of $112.00 per month. His invoices for July and August did not include this APTC. This has now been corrected and there will be an adjustment of $224.00 on his next invoice which will generate around August 8, 2015.If you have additional questions, please contact me directly.Linda S[redacted]Appeals CoordinatorPhone: [redacted]

October 16, 2015Revdex.com[redacted]
[redacted]
[redacted]Case ID:[redacted]Dear [redacted]:This is in response to your follow-up inquiry sent to us on behalf of the member identified by case ID [redacted].Our records show this member is enrolled on a Chip Gatekeeper policy effective September 1, 2015.The September 2015, premium payment in the amount of $61.75, was cleared by the bank on September 14, 2015. The paid to date on the account was updated to October 1, 2015, and denied claim number [redacted] was adjusted for payment on September 22, 2015. The Supervisor called the mother on September 15, 2015, and provided an update on the account, and the mother was satisfied with the outcome.Premium payments are due by the 15th of the month, and are applied to the next month’s coverage. The October 2015, premium was due by September 15, 2015, and the November 2015, premium is due by October 15, 2015, making the October 2015, premium past due.The enrollee’s mother called Highmark on October 7, 2015, and requested to speak with the Supervisor, but the Supervisor was out of the office due to a serious illness. The Supervisor has returned to work, and is in the process of placing a return phone call to address any outstanding concerns the mother may have.On behalf of Highmark, please extend my sincere apology to the enrollee’s mother for any frustration, or dissatisfaction she may have experienced in dealing with our Customer Advocates. Be assured we strive to provide efficient, courteous, and quality service, and are concerned when these standards are not met.I trust this addresses the mother’s concerns. If she has any questions, she can contact Customer Service at [redacted]. Should you have additional questions, please contact me directly.Sincerely,Janice M[redacted]Executive/Legislative Inquiries

April 7, 2017Revdex.com400 Holiday Drive, Suite 220Pittsburgh, PA 15220Attn: [redacted]Case ID: [redacted]Dear Ms. [redacted]This is in response to your inquiry sent to us on behalf of the member identified by Case ID [redacted].Although this member advised she had contacted Highmark West...

Virginia over 25 times to cancel her coverage, please note our records show her first contact to Highmark West Virginia in 2017 was on March 16, 2017. Through investigation, it was determined that she had making her requests to an outside national producer not affiliated with Highmark.Our policy is to cancel coverage the first of the month following notification, which would be April 1, 2017. Currently, our records show an April 1, 2017 cancel date.While I understand she feels she had cancelled her coverage, our records show prescription benefits were utilized in January and February, However, please know that a request to allow a retro cancellation of the policy has been made, but is still pending. The member will be advised once a decision has been made.If the member has any questions concerning this coverage, please have her contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly. Sincerely, Margueritte M[redacted]Executive Legislative Inquiries

June 24,2016Revdex.com[redacted]
[redacted]Attention: [redacted]
[redacted]Dear Ms. [redacted]:This is in response to your inquiry sent to us on behalf of the member identified in your inquiry by Case ID [redacted], and their recent, additional comments related to our previous responses submitted to your office.A review of our records located recent correspondence received from the member which included a provider billing statement that provided the required information to forward additional reimbursement to the member. Therefore, an additional payment has been forwarded to the member on June 23, 2016. They should receive the updated Explanation of Benefits statement and check/payment within the next seven (7) to ten (10) days.Combining the initial payment originally paid to the member, and the recent payment that has been forwarded to them, reimbursement for the total charges related to the services in question has now been made directly to the member. Therefore, forwarding payment to the out-ofnetwork provider for the services the patient received would be considered the responsibility of the patient.If the member has any questions concerning this information, please have them contact Customer Service at [redacted]. If you have additional questions, please contact me directly. Sincerely, Margie L[redacted]Executive/Legislative Inquiries