EmblemHealth

I mailed a claim for an out of network provider that I had paid for and after a month I called GHI/Emblem health and they said they never received my paperwork, even though I sent it to the correct address. Again I mailed in my paperwork and emailed them as well as called. This time 2 months later. I was told processing takes a while, when I asked why, she could not give me an answer. I have been paying into GHI for 25 years! I have paid way more than the $1500 I spent on the doctor. You would think they would have COURTESY! If they are that short staffed they need to hire more people. Now it is 3 months! No check! I am retiring in a few months and I am definitely switching my insurance company.

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 and the matter has been resolved.
Sincerely,
[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 and the matter has been resolved.
Sincerely,
[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 and the matter has been resolved.
Sincerely,
[redacted]

emblem health ghi. I am so sorry I switched from HIP prime to GHI. I can't sneeze without a co-pay. Office visits $30 test co-pay $20. With Hip prime I didn't have a co-pay or test co-pay. I will switch back to HIP prime next year. GHI sucks! Don't make the same mistake.

Review: My daughter had cause to visit the ER on June **,2013. Emblem Health claimed they issued a check for the resulting bill sometime in August of same year. It is February ,2014 and I have yet to see that cheque. I called them on January **, 2014 and spoke to a rep. giving her new address information since I had moved. She let me know a stop payment would be made on first cheque and a second one would be reissued. She also advised that I would receive said cheque within seven (7) to eleven (11) days. Today is February *,2014 and several calls later and I still haven't received anything. They are promising another wait of thirty (30) days. The situation is made even worse since the outstanding medical bill has gone into collections. How can this be allowed? How can this be fair when insurance premium has been paid faithfully and on time each month. This is disgusting!!!Desired Settlement: Expedited delivery of service. My good credit is at stake!!

Business

Response:

Here is the response we have on this member, member issue resolved , he recieved check.

Hi [redacted],

Review: On May **,2013, I had surgery for [redacted].My [redacted] and I [redacted].I used an out of network plastic surgeon,[redacted].I am entitled to use out of network doctors according to the insurance company.My plastic has not been paid as of today, September **.When the doctor originally filed the claim,the company said documentation was missing.The doctor refiled the claim with the documentation over 35 days ago and they have still not been paid.I have called Emblem Health about this many times.customer service representatives keep telling me it has been approved, but it is a high dollar amount. Why should this take so long? I feel that I am being punished because I used an out of network physician.Also the doctor's office is now submitting me bills.It should not take this long to process a claim.All of my claims by network doctors have been processed.I feel as if the company is discriminating against non network providers.The claim should be paid in a timely fashion whether the doctor is in the network or out of the network.Currently I am in danger of losing my plastic surgeon if my bill is not paid.Desired Settlement: Pay the bill

Business

Response:

Dear [redacted]:

This letter is to acknowledge receipt of and is in reply to your inquiry on behalf of [redacted], which was received on 09/**/13.

In accordance with the Health Insurance Portability and Accountability Act of 1996, we are prohibited from releasing Personal Health Information without a signed authorization to release information form from

[redacted]. Kindly be advised that we are in the process of investigating the issues and a response will be sent to [redacted] shortly.

Senior Specialist

Grievance and Appeal Department

Review: EmblemHealth started re-processing old bills (over a year and a half) to hospitals and doctors withdrawing their payments and the providers asking me to pay.

I believe EmblemHealth does that because I'm no longer a customer and although legally they have the right to do it, I find it unethical.Desired Settlement: I want EmblemHealth to stop reprocessing old claims and leave them paid as they were for years now.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me and the matter has been resolved.

Sincerely,

Review: I submitted a claim for medical care received on 1/**/2013 and the provider submitted the bill to GHI for processing ($665.00). GHI denied the claim saying that it was cosmetic (despite the fact that it was not, and similar charges had been filed and paid for the same condition in the past) I submitted the doctor's notes to appeal on May **, 2013 and received no communication from GHI. On July **, 2013 I send a message on their web site asking about the appeal and received a note back saying that they had received the paperwork and to please allow more time for review. I sent a note again on January **, 2014 to inquire about this claim as I still have received no communication regarding my appeal. Today I received a response from GHI, saying that they never received any appeal information for this claim, in the same thread that contained the original note indicating that they had received it.Desired Settlement: I want them to pay the claim. I think its ridiculous that they require customers to submit appeals within 6 months but then expect completely open ended time to process the claim and then pretend that they don't have the information. This is the second time I have had to submit a complaint regarding this company to get them to honor a covered service.

Business

Response:

Please review the attached response made by our Grievance and Appeal department in reference to this complaint submitted by the Revdex.com on behalf of [redacted].

Member will be supplied with appeal rights she can follow if she wants to appeal decision.

Review: On January [redacted] 2015 my 3-year old daughter, [redacted], injured herself while playing at home resulting in a [redacted] (with significant bleeding). We brought her to the ER at St. Barnabas Hospital in [redacted].

The ER staff told us only a plastic surgeon could close the wound with stitches. I asked about cost and was not given information on pricing but was assured that they would work with my insurance company to pay for the procedure. I also asked the plastic surgeon when he arrived about cost. Dr. S[redacted] he said he had worked with GHI before and would seek reimbursement for all costs. This put me at ease so I could comfort my child.

On November *, 2015, the plastic surgeon (Dr. S[redacted]) balance billed $423.50 for the ER visit (code [redacted]-Emer Dept Moderate Severity) + $3,354.12 for the stitching (code 13131, noted above) and $363 for after-hours work (code 99053).

My insurer, GHI/Emblem Health (Network CBP, my member ID #[redacted]) paid for the following:

$429 of $3,354.12 for stitches

$36 of $423.50 for ER visit

$0 of $363.00 for after-hours ER visit.

The plastic surgeon's office (Dr. S[redacted]) appealed twice with GHI Emblem and I received a surprise balance-bill for $3,675.62 in November 2015.

I have tried to file appeals with GHI / Emblem and they said that I was beyond the 180 days from final determination to appeal. They therefore declined my appeal. This is unfair since I did not find out about the denial until well after the 180 days nor was I CC’ed on correspondence between GHI and my plastic surgeon’s office.

Timeline:

Jan **, 2015 Emergency Room Visit.

March *, 2015 Emblem says they received claim from healthcare provider.

March *, 2015 Emblem mailed me a check for $465 which I signed over to surgeon's office, I had no knowledge of the billing amount at that time.

March **, 2015 Surgeon's office told me (told me Nov. 2015) they submitted appeal on this date. GHI confirms this.

November **, 2015 I receive balance bill for $3,675.62 from plastic surgeon.

November **, 2015 I write an appeal letter to GHI Emblem. I was also instructed by a customer service representative to file a “New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form” which I sent along with the plastic surgeon’s bill.

December **, 2015 In a letter from GHI Emblem I am told that “services rendered prior to April *, 2015, do not fall under or are reviewed as a Surprise Bill.” As well, that I am outside the 180 calendar days of the date of the claims determination.

I believe that GHI Emblem has an obligation to its members to pay claims on their behalf. This should especially be the case for an Emergency Room visit for a child.

I thank you for listening to my concern and I [redacted] that you can be an advocate on my behalf.Desired Settlement: I think GHI / Emblem should honor its obligation to it's members and reimburse the healthcare provider. This was an emergency room visit for a small child who was bleeding profusely from her head. The ER staff did not allow an ER doctor to perform the stitching procedure and my role was to be a comforting parent as opposed to worrying about the billing procedures of a health insurance company.

I was billed under my deductible for a [redacted]y related to [redacted] screening, instead of being covered in full with a co-pay. I was told this morning by Emblem Health customer service rep [redacted]. (she refused to give her last name, said it was prohibited) that [redacted] screening is not covered in full by my plan. [redacted] said she spoke to her [redacted] who said [redacted] screening is not covered under the Affordable Care Act. [redacted] then read off a list of covered procedures, which did not list [redacted] screening. But, on 3/*/15 when I called, I was told very specifically by another customer service rep that, under the Affordable Care Act, this was covered in full unless they found something and had to do an additional procedure; then it would fall under my enormous deductible. She said the information was on their website. So I had a screening colonoscopy in March based on that information and the information on their website. The physician also assured me it was covered. I read the Act and it is to be covered in full, but Emblem refused to pay. After a couple calls my physician's office called me back and said they spoke to someone higher up at Emblem and it's being reprocessed to be covered in full. But how many people have such diligent staff assisting them?

Crooks, Crooks, Crooks! Whatever you do, DO NOT sign up with Emblem Health. I had the most terrible experience with them, and when I finally switched over to a new health care provider, the continued charging me!!! I must have called over 10 times for a refund and all I got was the run around every single time, I even had people hang up on me. Suffice to say, that I will not be getting my premium pmts back. I think this is a scam that they run to keep charging people even after you cancel with them... Aside from that, the service was terrible! The networks have the worst doctors, co-pays are extremely high, and the customer service at Emblem itself has to be the absolute worst I have ever experienced!!! My wife and I are now covered with Empire Blue Cross Blue Shield and the difference in service is day and night... So, if you're even considering EmblemHealth as your healthcare provider, do yourself a favor and DON'T. Trust me, it is not worth it...

Review: I have a toothache since July*, my Dentist submitted a claim to my health insurance company for approval.. I received a response on July ** that it was denied because I was over 21 years and only could be approved if the #14 tooth supported a bridge which it did. someone did not notice the xray and documents from the dentist that I had a bridge. I have been trying to get the company to approve the claim because I am still in pain because I cannot afford the toothache I have been getting the run around. My phone calls are being ignored and no response. I even received a letter that I wanted to cancel my judgment which I have no concept. Allegedly they want me to get discourage.Desired Settlement: I just wanted to have the matter resolved to avoid the endless tooth ache and the pain killer pills that they keep recommending and this is coming from the customer service representatives when I call, is that legal? I have the documentation from the insurance company about being over 21 years and only would be approved if it is supported by a bridge.

Business

Response:

Dear [redacted]:

At HIP, we strive to provide you with access to a wide range of quality health care services that meet your needs. So when we deny coverage for a treatment or service, we want to make sure you know why.

We are responding to your Action Appeal received on 7/**/13 for a referral for root canal therapy on tooth # 14.

Our Enrollment Department's records indicate that you are enrolled under a HIP Medicaid Managed Care Program. As per your Member Handbook, Part II, Your HIP Coverage, Page 12, Dental Services include: routine exams, x-rays, clem1ings, fillings, tooth pulling, emergency treatment, root canal and oral surgery (under certain conditions).

Please note that based on the NYS MMIS Guidelines, specific criteria must be met in order to provide coverage for a referral for root canal therapy. Based on the information provided to us by Healthplex from your Healthplex participating provider, you do not meet the coverage requirements.

Your request was carefully reviewed and considered by a Consultant in our Dental Department.

Using the information provided, the conditions present in your mouth and the NYS MMIS Guidelines, which are the criteria established by New York State to administer your dental benefits, we are upholding the initial denial. This means that we will not cover the following services or items that you or your provider requested: referral for root canal therapy on tooth #14.

However, we suggest that you contact your general dentist to discuss functional alternatives and to ensure the continuity of your dental treatment.

If you have any questions about this decision, you or your authorized representative may call me at ###-###-#### or Customer Service at ###-###-#### or write to HIP Grievance and Appeal Department. [redacted].

What If I Don 't Agree With The Decision?

You may have the right to file a Fair Hearing if you disagree with our decision. Please see the enclosed document: Important Information about vour Fair Hearing Rights for more information.

Sincerely,

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID# [redacted], and have determined that my complaint has NOT been resolved because:

The insurance company refuses contact the dentist for the rest of the document to resolve the dilemma, I mentioned to the supervisor tha [redacted] told me to pay $300 in order to start the process. That illegal because I already have insurance. The pain an suffering started on th [redacted] of July until today. All this finger pointing from the doctor to insurance company via versa.

In order for the Revdex.com to appropriately process your response, you MUST answer the question above.

Sincerely,

Business

Response:

Dear [redacted],

The response letter was a formal Plan decsion on this member ( [redacted]) and his complaint concerning denial of dental treatment for specific root canal. The letter provides the member with his appeal rights and next steps in pursuit of the final resolution for HIP Medicaid members through the State Fair Hearing process.

Emblem Health will not provide any further response until member files for and goes through Fair Hearing process as allotted by his coverage.

[redacted],

Senior Director Customer Service

Review: On July **, 2013, I went to my primary doctor for an annual physical checkup. I am entitled to annual physical exams according to my policy (please see Attachments 1 & 2). After my physical checkup, my primary doctor sent me to Quest Diagnostics to get routine blood tests done. I went on July **, 2013 to get the blood work done.

On August **, 2013, I received two bills from Quest Diagnostics for $1,385.20 (See Attachment 3). EmblemHealth did not pay any portion of the bill (See Attachment 3). The blood tests were routine tests ordered by my physician, nothing extra (See Attachment 4 for blood tests performed).

I have contacted Emblem several times and they refuse to pay for the blood tests without stating a reason. They only say blood work is not covered in the policy, but fail to show any benefit documents to confirm this. The summary (Attachment 1) and policy (Attachment 2) clearly state that I am entitled to an annual physical and clinical laboratory tests. There are no asterisks or footnotes to denote that blood tests are excluded, or if there are any exceptions or limitations to this. In fact, my physican also believes that I am entitled to routine blood tests and he was baffled by my bill from Quest Diagnostics. Otherwise, my physican would have informed me that blood work was not covered and I would not have gone to Quest Diagnostics to get it done. On that day, Quest Diagnostics also informed me that my blood work was covered by my insurance.

Emblem has unethical business practices. They refuse to pay for health services that are clearly included in the policy. We are a non-profit organization, and we cannot afford to pay for outrageous health bills. We only use health services that we know are covered. EmblemHealth needs to own up to its responsibilities and pay for these clinical lab bills for routine blood work as stated in their policy.

** I cannot upload these attachments on this site. Attachments can be sent upon request.Desired Settlement: EmblemHealth needs to pay $1,385.20 in health bills.

Business

Response:

We never received authorization from the member. Therefore, we cannot disclose any of the results regarding this case. We responded directly to the member on 3/**/14. I hope this helps.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me and the matter has been resolved.

Sincerely,

Review: GHI contracts with[redacted] to approve [redacted] treatment. Even though I have been diagnosed with a [redacted], and have been prescribed [redacted] by medical doctor, [redacted] has initially denied paying for treatment. They delay my receiving treatment, while I am in pain, with continuous requests for more documentation.Desired Settlement: Stop delaying treatment

Business

Response:

Dear [redacted]:

This letter is to acknowledge receipt of and is in reply to your inquiry on behalf of [redacted], which was received on 09/**/13.

In accordance with the Health Insurance Portability and Accountability Act of 1996, we are prohibited from releasing Personal Health Information without a signed authorization to release information form from

[redacted]. Kindly be advised that we are in the process of investigating the issues and a response will be sent to [redacted] shortly.

Review: Emblem requires my Pharmacy ( [redacted]), a mail order business to have a authorization from my doctor to fill a prescription for [redacted] ( a [redacted] med) or they will not cover the drug even though it is in their formulary. They want medical records. I maintain if my doctor wrote the prescription that is all they need to knowDesired Settlement: Stop making me and my doctor jump through unnecessary hoops for me to get my meds. If my doctor wrote the script and my insurance covers it then they do not need an "authorization" from my doctor and they do not need any medical "backround" on me. This is an attempt to delay paying for a drug they are contractually obligated to supply payment for.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me and the matter has been resolved.

Sincerely,

very limited options even with gold plan.