EL NIPLITO DEL SURESTE

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. 
Regards,
[redacted] My complaint was resolved to my satisfaction. Highmark has agreed to cover my health bills because of an error on there part. This was all I was asking of them. Thank you [redacted]

December 20, 2016Revdex.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.In her complaint,...

the member states that she and her husband enrolled in coverage through the Federally Facilitated Marketplace (FFM) in February 2015. She states that at the time of enrollment, they were advised their son was eligible for Medicaid, and could not go onto their Highmark policy. She states that Medicaid advised them that he was not eligible, and at that time they contacted the FFM to have him added to their Highmark coverage. A couple of months after adding him onto their policy, they were notified that their son did qualify for Medicaid and they received his Medicaid card. They again contacted the FFM and had him removed from their Highmark policy.The member further states in her complaint that her husband’s birthdate was initially incorrect on the FFM enrollment file, causing Highmark to invoice them the incorrect premium for several months. She states that after several attempts to have the billing corrected, they received an invoice which stated they owed Highmark over $700 to bring the account current. Because they were advised they must pay this higher premium or lose their coverage, she states her husband was forced to go without his medications for a month. The member is asking for someone to review the account, and ensure that there are no more issues with the billing.Highmark has reviewed the member’s account. On February 26, 2015, Highmark received an enrollment file from the FFM. This file included the member and her husband only, effective March 1, 2016. This application had the incorrect birthdate for her husband. On April 3, 2016, a new enrollment file was received from the FFM. This file had the correct birthdate for her husband, which resulted in adjustments to the billing to correct the previously invoiced amounts.On August 26, 2015, another file was received from the FFM, which placed the member’s son on the policy retroactive to March 1, 2015, and cancelling his coverage effective August 6 2015. This file however, did not include his premium. He was added to the policy, but the billing was not updated. It was not until August 2016, when the September invoice was generated, that the account was adjusted to reflect their son’s premiums for the six month he was on the policy in 2015. This resulted in a significant balance to the member.Upon reviewing the account and speaking to the member, Highmark has made the determination to write off the premiums they paid for their son. Medicaid had covered him from his date of birth, and the updates sent to Highmark from the FFM were not accurate. The total paid in premiums for their son was $709.42, and a refund in that amount was issued on December 16, 2016.On behalf of Highmark, I apologize for any anxiety or frustration the member experienced as a result of these matters. We strive to provide efficient, courteous and quality service. Even when these standards are not met, we are continually working to improve our service to meet the needs of our valued customers.If you have additional questions, please contact me directly.Sincerely,Linda K[redacted]Executive/Legislative InquiriesPhone: [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Regards,
Amy KohrAttention [redacted]Complaint #[redacted]I have attached two documents  The first, Claim 1 shows how my original claim processed to show I owe nothing.  Which is why for 9 months I was told I owe nothing.  The second document, Claim 2 shows that on some unknown date they adjusted my original claim and charged me $55.75  You don’t after 9 months decide to adjust a claim for no apparent reason.  I can’t tell you the numerous people I spoke to at Highmark over that nine month period who assured me I owe nothing and to disregard the bill.  I can’t believe there are that many incompetent people working there.  The reason they told me I owe nothing is because it was showing them, on their end, I owe nothing. Or are they going to try to say, yes these people could see I owe the $55.75 but they all decided to tell me for nine months I didn’t.  I don’t think so. This is why I am still disputing this charge

June 13, 2016Revdex.comAttn: [redacted]Case ID: [redacted]File Number: [redacted]Dear Ms. [redacted]:This is in response to your inquiry sent to us bn behalf of member identified by the Case ID number noted above.In her complaint, the...

member stated Highmark has not made it easy for her to make the monthly premium payments on time. She stated that Highmark did not send her invoices for the first three months of 2016. The member stated she has called Highmark every month to make her payments. In April 2016. her policy was cancelled due to a Highmark system error and it took Highmark three weeks to reinstate the policy. The member stated she set up automatic payments and was over charged in June. She stated Highmark cancelled the overpayment without asking her and she does not know if her family has insurance coverage now. The member stated she was advised by Highmark that she cannot make another payment until an invoice has generated, which will not be until the end of June. She stated they cannot get their prescriptions and that they will how be going another month wondering if they have insurance or not.The member has active coverage with an effective date of January 1, 2016. Highmark has sent out invoices to the member each month. She made her May premium and then set op the reoccurring payments through the Highmark member portal. When members set up reoccurring payments the payment that is taken reflects the amount on the invoice. The double payment of $1,166.42 was taken because her May premium payment posted to her account one day after the invoice for June was generated. Therefore, the amount due on her invoice showed a total of $1,166.42 due for May and June.On May 31, 2016, the member contacted Highmark to find out why there was a double payment taken and if anything needed to be done so this would not happen again. The Customer Service Advocate (CSA) advised the member why the double payment was taken and the best way to correct the overpayment would be to refund the payment of $1,166.42. Once the refund was requested she was advised to make a payment of $583.21 for June. She stated she did not want to be refunded. However, the CSA requested the refund before confirming this. The CSA advised the member the refund had already been submitted and could not be reversed.The member agreed to continue with what she had been advised and was willing to make the payment for June. The CSA did not verify if there was a payable invoice to take a payment and she was not able to make the payment. The CSA advised her that she does have a 90 day grace period, so her claims will still pay and she will still be able to pick up her prescriptions. Staff education has been provided to the CSA.The member’s credit card has been refunded. However, the invoice for July does not show this. The invoices should show the update with the next billing cycle, but this can take up to two billing cycles to reflect the corrected amounts. I will continue to monitor the member’s account to verify no other issue arise. She currently is paid to June 1, 2016, and owes $583.12 for June.On behalf of Highmark, I apologize for any anxiety or inconvenience this issue may have caused. If you have additional questions, please contact me directly.Sincerely,Michelle D[redacted]Appeals CoordinatorPhone: [redacted]

March 6, 2018Revdex.com Attn: [redacted] 400 Holiday Drive, Suite 220 Pittsburgh, PA 15220Case ID: [redacted] File Number: [redacted]Dear Ms. [redacted]:This is in response to your inquiry sent to us on behalf ofmember identified by the Case ID number noted above.In her complaint, the...

member stated that she believes that Highmark intentionally ignored correspondence she submitted in order to appeal the processing of a claim applying toward her out-of-network deductible. She feels that the claim should have processed toward her in-network level of benefits, and that Highmark should pay the balance of $3,319.66 to Lourdes Hospital, New York, because her physician is licensed in. and practices in, both Pennsylvania and New York.Highmark has reviewed the member’s account, including the claim in question, the benefits of her policy in effect on the date of service, as well as the associated inquiries, On August 2, 2016, the member had services rendered at Lourdes Hospital, New York, which is outside the thirteen county area serviced by her contract. The terms of the policy only provided benefits at the in-network level when using participating providers within the thirteen county region outlined in her contract. The claim in question processed correctly. The claim priced at the low-level in-network benefit, and applied toward her out-of-network deductible.Under the terms of the member’s contract, utilizing an out-of-network provider, the claim would be priced at a low-level in-network cost, and process toward the out-of-network benefits, and the provider would not balance bill the difference. In this ease, the provider submitted a total charge of $6,200.01, The eligible amount was $3,319.65, which applied to the member’s out-of-network deductible. The provider cannot balance bill the difference between the total charge, and the eligible amount.The letters that the member sent to Highmark in December 2016, January 2017, and May 2017, were addressed to an Enrollment address, where letters of disenrollment would be mailed. They were not sent to the appropriate Appeals address that was printed on her Explanation of Benefits (EOB). Unfortunately, due to this, they were not processed appropriately; however, in June 2017, the letter that she sent in May, was forwarded to the appropriate appeals queue. At that time, the appeal was denied, because the Appeals Analyst did not have the previous letters, and denied the appeal because it was past the 180-day timeframe for an appeal to be processed.On July 9, 2017, the member sent another letter to Highmark. This letter was addressed to one of the Appeals addresses. The appeal was processed, and the member was advised that the claim processed correctly according to the terms of her contract. Highmark understands that the member feels this service may warrant payment at a higher level than the allowed amount; however, claims are processed and reimbursed according to the terms of the agreement and the provider’s participation status at the time of service.If you have additional questions, please contact me directly.Linda K. Executive/Legislative InquiriesPhone: [redacted]

June 12, 2015 Revdex.com Attn: [redacted]  [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 her complaint, the member states that she did not receive an invoice for the April coverage period.  The member states she called Highmark Customer Service on April 6, 2015, and was advised that the policy would be reinstated, and that the reinstatement would take two to three weeks.  On June 1, 2015, the member received an invoice in the amount of $532.17 for the April, May, and June coverage periods.  The member further states that she called Highmark to cancel her coverage after receiving that invoice, as she felt she should not be held responsible for premium payments for the months she felt she did not have coverage.   The member wants to cancel her coverage and to have an account balance of $0.00.  After reviewing the member’s account, I have determined that the policy did in fact cancel in error during the month of March.  This cancellation was reversed and processed on May 21, 2015.  With a reinstatement, the policy would be reactivated with no lapse in the coverage, and the member would be responsible for the premiums for that time period.  Any medical services or prescriptions paid for by the member could still be submitted for processing according to the terms of the policy.  We have received a cancellation request from the Federally Facilitated Marketplace (FFM) effective June 16, 2015.  However, because the member is paid to April 1, 2015, the policy will be retroactively cancelled back to the paid to date, and the member will not owe any further premiums.  If you have additional questions, please contact me directly.                                           ...⇄ Sincerely,                                           ...⇄ [redacted].                                         ...⇄ Appeals Coordinator                                         ...⇄ Phone: [redacted]

I have several disagreements and issues with Highmark’s reply to my complaint #[redacted]. First, Highmark Blue Shield presented online and in its surgery authorization that Lourdes Hospital as an “in network” site.  As such, I chose that location because it is a shorter distance to and much easier facility to access from a time and transportation standpoint.  As I was in considerable pain, this was the logical choice. Second, I did not “invent” the address to which I sent my claim.  In all of my years as client/customer of Blue Cross/Blue Shield, I had never had an issue or complaint with the company.  I telephoned Highmark to find out where I should send my complaint, and that is the address that I was given.  Third, bearing in mind that I cannot be the only client/customer that was either given an incorrect mailing address or inadvertently sent a complaint to an incorrect address, I find it unbelievable that Highmark has such an incompetent interoffice mail system that my complaint was not transferred in a timely manner to the correct department. Fourth, months after Highmark finally addressed me and my complaint at all, the correspondence has come from Pittsburgh and not Camp Hill.  How can it/could it have been that sending the complaint to Pittsburgh in the first place would not engender any response? Fifth, in addition to writing to Highmark about my complaint, I spent a considerable amount of time on the phone calling customer service trying to sort this matter out.  I was told different things at different times, not the least of which was that my complaint claim had been processed through the New York division of Highmark rather than the Pennsylvania division through which my insurance coverage was based, and again, that Lourdes was in the Highmark Blue Shield/Blue Cross network.  It seems to me that my policy should have followed me and not Highmark’s office processing system.  Sixth, my deductibles had already been met by the time of the August 2016 surgery. Seventh, my August 2016 surgery was a critical corrective/followup surgery to that which I had the year before by the same doctor.  Any smart claims authorization/processing person would see that and address my situation accordingly.  From the time of the first issuance of the Explanation of Benefits in November of 2016, following the actual surgery in August 2016, and my initial complaint made in December of 2016, to this point, is extraordinary.  At the very least, it implicates Highmark Blue Cross/Blue Shield as incompetent in handling my claim and that the company has acted in bad faith as an insurer.  Therefore, my request for Highmark to pay the remainder of my claim remains.   [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]I received a letter asking me to forward the bill to BCBS, which I did.  I will be really happy to close this case as soon as know the bill is paid.
Regards,
[redacted]

December 10, 2015Revdex.com[redacted]Attention: [redacted]Case ID: [redacted]Dear [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 additional concerns related to our original response submitted to your office on October 20, 2015.On October 9, 2015, a letter was sent to the member along with a copy of the cancelled check issued to the member, dated January 24, 2014, which was related to the claim in question. This same letter also provided the member instructions on how to contact our office once the amount associated with this cancelled check was forwarded to the provider, applied to their account, and a bill for the remaining balance was received from the provider. To date, our records indicate the member has not contacted our office to provide this information. For consideration of the remaining balance, the member should refer to the instructions provided in this letter.If the member has misplaced our letter dated October 9, 2015, or needs to receive instructions on how to forward the required information to consider their remaining balance, the member should contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly.Sincerely,Margie L[redacted]Executive/Legislative Inquiries

October 20, 2015Revdex.com[redacted]Attn: [redacted]Case ID: [redacted]Dear [redacted]This is in response to your inquiry sent to us on behalf of the member identified in your inquiry by Case ID [redacted].Our records indicate the claim in question...

was processed issuing a check to the member on January 24, 2014. Please recognize that a copy of the check was recently sent to the member on October 9, 2015, along with additional instructions pertaining to the balance on the claim.If the member has any questions concerning this coverage, please have the member contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly.Sincerely,Margueritte M[redacted]Executive/Legislative Inquiries

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]. The member is currently enrolled in a Preferred Provider Organization through an employer group with an effective date of June 1. 2017. This...

fully-insured nongrandfathered group has one level of appeal to be administered by Highmark with an external review available for medical necessity' denials only.The member has already received and paid for the services in question. He was instructed to submit a claim directly to Highmark. However, this member resides in California and Blue Cross Blue Shield Association guidelines require we forward the member submitted claims to the local plan to be entered and processed via. the BlueCard program. This process may take four to six weeks.The BlueCsrd program that is designed to allow Blue Cross Bine Shield plans to share the participating provider discounts and allowances with other Blue Cross Blue Shield Plans. This program is also designed, to hold members harmless for the difference between a participating provider's charge and the allowance. Claims are submitted to the provider’s local Blue Cross Blue Shield Plan. The local plan is considered the host plan and is responsible for pricing, allowances, transmitting the claim to the home plan and payment to She provider. As the home plan, Highmark verifies membership eligibility and benefits and transmits the claim back to the host plan for payment.Our records indicate that on December 13. 2017, our advocate advised the member that he would receive a callback, but only when our advocate was alerted of the claim showing on our system. Our advocated advised he could not guarantee an exact date. Once the claim has been entered and forwarded to Highmark, our advocate wilt contact the member.If this 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,Margueritte M[redacted]-S[redacted] Executive 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. I will not know for sure whether their response is accurate until approximately 3 weeks from now when I receive my invoice, but since I only have 10 days to respond I will accept the resolution for now until I receive my next invoice, in hope that it will truly be resolved. 
Regards,
[redacted]

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. 
Regards,
[redacted]

January 21, 2016Revdex.comAttn: [redacted]  [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 his wife’s health insurer is not allowing her to pick up her prescription.  He states that she is out of medication, and needs the prescription badly.  He states that his wife has been on this medication for several years and wants the prescription filled now. Upon review of the member’s account, the Highmark policy ended effective January 1, 2016.  Highmark contacted the member via telephone on January 8, 2016, and the member stated she enrolled in coverage through [redacted] Health plan for the 2016 benefit period.  Member was advised that if she is having difficulty filling her prescription at this time, they will need to contact the new health insurer.  The member and her husband explained that they had filed the complaint due to the difficulty in filling her medication during the month of December.  The medication that the member was prescribed, required a prior authorization.  She attempted to fill the medication on December 22, 2015, at which time she was advised the physician would need to submit a request for authorization.  The request was received on December 23, 2015.  On December 28, 2015, a call was placed to the physician to obtain additional information pertaining to the request.  Once this was received, the authorization was approved on December 30, 2015.  The member received her medication, delivered via FedEx on December 31, 2015. If you have additional questions, please contact me directly. Sincerely, Linda S[redacted]. Executive/Legislative Inquiries Phone: [redacted]

Revdex.com:
I was contacted today by Linda S[redacted] from Highmark to see if we had received the booklet.  I informed her all we had received was another ID card.  She stated she could see on the computer that again the booklet was not mailed and that she would print it and mail it on Monday the 29th.Also their response did not cover the fact that when my wife made the 1st payment on 04/10/2015 the booklet was not mailed at that time and was not mailed after my 1st or 2nd request or after my wife requested it.  I do not know which request was cancelled by mistake or even that I believe that as an answer at this point.
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]

June 24, 2015 [redacted] Revdex.com [redacted] Re: ID# [redacted] Dear [redacted]: We are in receipt of the Complaint dated June 8, 2015 regarding the member’s ongoing billing and collection issues.  The member had previously contacted...

the President of Highmark Inc. directly on May 25, 2015. The member’s account was reviewed with respect to the noted issues with payments not being posted to his account and revealed that the automatic payment feature with the member’s banking institution was set up with the incorrect billing account number which caused the payments to be directed to the wrong account. On Friday, May 29, 2015, the member’s payments were located and applied to the correct account.  The member’s paid to date was then advanced to July 1, 2015.  The member was contacted on May 29th and advised of the status of his complaint and the correction made to his account. By this point the new invoices for June had already been generated and mailed, which will account for why the June invoice remained incorrect. Highmark set up monthly monitoring on the member’s account to ensure that payments are posted correctly.  Upon further review on June 12, 2015, the member’s account is still accurate and his most recent invoice was also correct.  Highmark will continue to monitor this account. Highmark WV understands the frustration the member has experienced trying to get the matter resolved.  We appreciate the opportunity to advocate education with our billing team to understand why there continued to be an issue and what we could do to correct it so that other members would not experience the same issues. If we can be of further assistance, please contact me at the below email address. Sincerely, Courtney N. L[redacted], Associate Counsel [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below. my payments were taken each month, leaving me with the impression I was insured. if the company did not intend to insure me. they should not have collected my payments or waited until december to inform me that I was not insured.  i am rather disgusted with highmark and request my money back for the entire year. dr [redacted] should be paid what he is owed and my irs penalty should be taken care of. this does not even take into account all the hours of my time that was wasted on the phone being transferring from one 'csa' to the nxet
Regards,
[redacted]

Revdex.comServing Metro Washington DC and Eastern Pennsylvania[redacted]Attention: [redacted]ID Number: [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]...

regarding prescription drug expenses that the member incurred in September and October 2012.We have no record of the member questioning the processing of these 2012 charges until a recent contact was made to Customer Service on May 31, 2016, Because the member is questioning charges that were to have been reimbursed almost four (4) years ago, I have requested the claim information related to that time period. However, this information has been purged and will take approximately an additional seven (7) to ten (10) days to be retrieved. Once this information has been received, I will provide you with an updated response with additional information.I can, however, confirm that the prescription receipts that the member submitted indicating a payment was made to the pharmacy for $4.00, $6.00 or $8.00, was less than the amount of the prescription drug copayment that was applicable at that time under his benefit plan. In 2012, for up to a 31-day supply, the member’s benefit plan applied a $10.00 copayment for generic prescription drugs and a $30.00 copayment for brand prescription drugs, Therefore, our records indicate for the following dates of service, no reimbursement would have been due to the member because the cost paid to the pharmacy was less than the copayment that would have applied, per the member's benefits:Date indicated on prescription drug receipt Amount indicated as payment made to pharmacy9-7-2012 $4.009-7-2012 $4,009-7-2012 $4.009-7-2012 $8.009-7-2012 $8,0010-2-2012 $4.0010-3-2012 $6.00 Additionally, the prescription drug receipt dated October 3, 2012, indicating a patient payment of $30.00, was the correct brand prescription drug copayment that would have been the member’s responsibility. Therefore, no reimbursement would have been due for this charge,The member also submitted only cash register receipts for the following dates; July 12, 2012, July 19, 2012, July 29, 212, August 10, 2012, August 14, 2012, and August 21, 2012. These cash register receipts did not include a matching prescription drug receipt from the merchant’s pharmacy department, but the amounts indicated on these receipts indicate the costs associated with the member’s prescriptions were either less than the plan’s applicable copayment ($4.63 and $4.89), or the total amount of the generic drug copayment, $10.00, Therefore, there would be no additional reimbursement due for these charges. If the member has any questions concerning this information, please have them contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly.Margie L[redacted]Executive/Legislative Inquiries

Case ID: [redacted]Dear Ms. [redacted]:This member idenilfied has a FlexibIe Spending Account (FSA} through Highmark. 0ur records indicate this member contacted our Customer Service Department on March 21, 2018, concerned about issues with her Flexible Spending Account,, and she was advised that...

a few of her transactions were not eligible per IRS guidelines.This-member had been using her FSA debit card for expenses incurred in the prior plan year and submitting balance forward bills from the prior plan year. The card can only be used for current year expenses. We require itemized receipts or the full Explanation of Benefits statements to confirm that the expense is an eligible IRS expense.Please know our records indicate a supervisor contacted this member on March 22, 2018, per her request to the Customer Service Advocate.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, Marguenue M[redacted]-S[redacted] Executive Legislative Inquiries

Case ID: [redacted]Dear Ms. Gasser:This is in response to your inquiry sent to us on behalf of the member identified by your Case ID [redacted].The member was enrolled in a Preferred Provider Organization (PPO) plan through an employer group from July 1,2005 to March 1,2017. This self-insured...

non-grandfathered group has two levels of appeal to be administered by Highmark with an external available for medical necessity denials only.As the member indicates, she was advised a payment would be issue to her due to incorrect information being provided regarding immunizations. According to our records, a request was forwarded to have the claim’s payment issued to her, but it has not finalized as the initial payment was issued to the provider inadvertently. The payment is being retracted from the provider and will be issued to the member.While I understand that the member is requesting interest, please recognize that we are unable to reimburse a nonmedical expense.If the member has any questions concerning this coverage, please have her contact our Customer Service Department at ###-###-####. If you have additional questions, please contact me directly.Sincerely, Marqueritte M[redacted]-S[redacted]Executive Legislative InquiriesEnclosures