Employee Benefit Specialist

June 2015Dear [redacted] ***,I had to respond after reading the obvious prevarication that MrM [redacted] sent to you the other day [redacted] does not handle our excess out of network benefit claimsAs you can see from the attached form that my employer provided us, the statement that [redacted] has our contracts and handles the out of network claim processing for final payment is a lieThe attached form is sent to EBS by the employee with a copy of the estimation of benefits after the claim is processed by [redacted] ***EBS then calculates what is owed to the employee, and then sends it off to [redacted] to be paid out of an HRA account for out of network claims onlyThe plan has a $20K out of network deductible, but because of our police contract, in reality it is a Sdeductible per person and then the plan pays 70% of what is usual, customary and reasonableM [redacted] has handled other employees with their out of network claims, but only mine have been ignoredCould it be because I was the president of the police association, and we fought over not having a debit card and won? While I can’t prove that allegation, I can prove that they have not processed my claims that were sent to EBS multiple times, and that they are the folks who are responsible for doing thatThe form speaks for itself, and I am appalled at his feigned ignorance.Submitted,

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: the township contracted with EBS to process the out of network claims, and submit them to [redacted] for paymentThere have been clients with out of network claims, but mine were the only ones that EBS failed to process for payment [redacted] processed the original claim, and then it's submitted to EBS since it's an excess benefit that is granted by contractRob promised to resolve this months ago but he has done nothingIt's not an attack when it's the truthProcess the claims and pay themI can provide you with a copy of the claim for that goes to EBS if you are interested Regards, [redacted]

6/7/2015Dear ***,I am formally responding in writing to the complaint registered by a *** ** ***, insured employee of Tredyffrin Township's group medical benefit planTredyffrin Township has been insured with *** *** *** from 5/1/through 4/30/The plan of insurance is a
high deductible health plan purchased through *** *** *** (***)*** is the adjudicator of all claims for this fully insured contractFurthermore, Tredyffrin Township contracts directly with *** to administer a supplemental Health Reimbursement Arrangement (HRA) that is funded by the Township, administration fees paid for by the Township for services providedTredyffrin Township has contractual arrangements with their union members to deliver benefits according to the contracts*** has copies of all the union contracts so they can properly administer the plans, not meMy role as a health insurance agent and broker has been to serve as a liaison between the Township and ***I helped design the plan, communicate and educate employees on how to best take advantage of their benefit plansI have on multiple occasions used my relationships with *** to help resolve problems that are intrinsic to a claim intensive business such as health insurance.I understand that *** ** *** is frustrated and has chosen to use this approach to attack myself and my companyI am not the adjudicator of claims or the administrator of Tredyffrin Townships HRAI do not have the ability to make determination in the claim payment processI have setup multiple meetings with high level *** claims managers and the management of Tredyffrin Township to address all the outstanding claim issues including *** ** ***I have provided all the contact information for *** account executives, claim managers to Tredyffrin Township management that have the final responsibility for cleaning up any outstanding claims on this case.I have been in business for over years and have never had one complaint about the quality of the Service my company provides to the companies that we serve or their employeesMy company has the highest reputation, integrity, ethics and service level.SincerelyRobert M.President Employee Benefit Specialist, Inc

6/7/Dear ***,
I am formally responding in writing to the complaint registered by a *** ** ***, insured employee of Tredyffrin Township's group medical benefit planTredyffrin Township has been insured with *** *** *** from 5/1/through 4/30/The plan
of insurance is a high deductible health plan purchased through *** *** *** (***)*** is the adjudicator of all claims for this fully insured contractFurthermore, Tredyffrin Township contracts directly with *** to administer a supplemental Health Reimbursement Arrangement (HRA) that is funded by the Township, administration fees paid for by the Township for services providedTredyffrin Township has contractual arrangements with their union members to deliver benefits according to the contracts*** has copies of all the union contracts so they can properly administer the plans, not meMy role as a health insurance agent and broker has been to serve as a liaison between the Township and ***I helped design the plan, communicate and educate employees on how to best take advantage of their benefit plansI have on multiple occasions used my relationships with *** to help resolve problems that are intrinsic to a claim intensive business such as health insurance.I understand that *** ** *** is frustrated and has chosen to use this approach to attack myself and my companyI am not the adjudicator of claims or the administrator of Tredyffrin Townships HRAI do not have the ability to make determination in the claim payment processI have setup multiple meetings with high level *** claims managers and the management of Tredyffrin Township to address all the outstanding claim issues including *** ** ***I have provided all the contact information for *** account executives, claim managers to Tredyffrin Township management that have the final responsibility for cleaning up any outstanding claims on this case.I have been in business for over years and have never had one complaint about the quality of the Service my company provides to the companies that we serve or their employeesMy company has the highest reputation, integrity, ethics and service level.SincerelyRobert M.President Employee Benefit Specialist, Inc

16 June 2015Dear [redacted],I had to respond after reading the obvious prevarication that Mr. M[redacted] sent to you the other day. [redacted] does not handle our excess out of network benefit claims. As you can see from the attached form that my employer provided us, the statement that [redacted] has our contracts and handles the out of network claim processing for final payment is a lie. The attached form is sent to EBS by the employee with a copy of the estimation of benefits after the claim is processed by [redacted]. EBS then calculates what is owed to the employee, and then sends it off to [redacted] to be paid out of an HRA account for out of network claims only. The plan has a $20K out of network deductible, but because of our police contract, in reality it is a S300 deductible per person and then the plan pays 70% of what is usual, customary and reasonable. M[redacted] has handled 19 other employees with their out of network claims, but only mine have been ignored. Could it be because I was the president of the police association, and we fought over not having a debit card and won? While I can’t prove that allegation, I can prove that they have not processed my claims that were sent to EBS multiple times, and that they are the folks who are responsible for doing that. The form speaks for itself, and I am appalled at his feigned ignorance.
Submitted,

16 June 2015Dear [redacted],I had to respond after reading the obvious prevarication that Mr. M[redacted] sent to you the other day. [redacted] does not handle our excess out of network benefit claims. As you can see from the attached form that my employer provided us, the statement that [redacted] has our contracts and handles the out of network claim processing for final payment is a lie. The attached form is sent to EBS by the employee with a copy of the estimation of benefits after the claim is processed by [redacted]. EBS then calculates what is owed to the employee, and then sends it off to [redacted] to be paid out of an HRA account for out of network claims only. The plan has a $20K out of network deductible, but because of our police contract, in reality it is a S300 deductible per person and then the plan pays 70% of what is usual, customary and reasonable. M[redacted] has handled 19 other employees with their out of network claims, but only mine have been ignored. Could it be because I was the president of the police association, and we fought over not having a debit card and won? While I can’t prove that allegation, I can prove that they have not processed my claims that were sent to EBS multiple times, and that they are the folks who are responsible for doing that. The form speaks for itself, and I am appalled at his feigned ignorance.Submitted,

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because: the township contracted with EBS to process the out of network claims, and submit them to [redacted] for payment. There have been 20 clients with out of network claims, but mine were the only ones that EBS failed to process for payment. [redacted] processed the original claim, and then it's submitted to EBS since it's an excess benefit that is granted by contract. Rob promised to resolve this months ago but he has done nothing. It's not an attack when it's the truth. Process the claims and pay them. I can provide you with a copy of the claim for that goes to EBS if you are interested. 
Regards,
[redacted]