Excellus Blue Cross Blue Shield

Attached please find the requested Excellus HIPAA form

Denial Upheld
On June 29, 2016, we received correspondence from the Revdex.com, on your behalf, requesting a
Level One Grievance regarding your financial responsibility for maternity services provided February 9,
through June 14, by *** *** *** *** *** and
DrWaguih SK***On July 29,
we completed our review and determined that our adverse determination should be upheld
Case Details:
Patient Name: *** *** Date of Service: February 9,through June 14,
ID Number: ***
Provider Name: DrWaguih SK*** and
*** *** *** *** ***
Type of Coverage: Insured Group Indemnity
Plan
Claim/Authorization Number: Multiple
Total Charges: $3,Reason for Denial: Deductible
Diagnosis and treatment codes and their meanings are available upon request
As we understand it, the Revdex.com indicated in the grievance request that you were concerned with
the wording on the benefit summary and explanation of benefits, as it indicated your prenatal bills would be
covered in fullHowever, you are receiving bills for services relating to maternity care such as laboratory and
radiology servicesYou would like the prenatal care bills to be covered in full as indicated in your benefit
summary
The basis for our Level One Grievance determination Is as follows:
We reviewed your verbal grievance request, the above claim submissions and your Preferred Provider
Organization Certificate of CoverageAccording to your contract, the member financial responsibility for
diagnostic office visits, laboratory services and radiology services such as ultrasounds, when provided by an innetwork
physician or facility, is 20% of the allowable expense, after the $2,individual deductible has been
satisfied in a calendar yearThe deductible is the amount you owe before we begin to pay for covered services
Additionally, according to your contract, prenatal and postpartum care is covered in full of the allowable expense
when rendered by an in-network providerThis care includes the routine services rendered by your Obstetrician
Additional services such as laboratory services, sick visits and radiology services are not considered routine
services under prenatal and postpartum care and have their own benefit listings.With regard to the services provided to you by *** *** *** *** *** and
DrWagulh SK***; we have confirmed both providers have an In-network participation agreement with us
Thus, *** *** *** *** *** and DrWagulh SK*** are categorized as an In-network
providers with your planWhen covered services are received from In-network providers, the in-network benefits
will apply
We have also confirmed based on the claim submissions that the health services you received are categorized as
a diagnostic office visit, radiology services and laboratory servicesWhen you receive covered health services, we
are responsible to consider and process the services for payment In accordance to the specific benefits listed in
your certificate
We have verified the calendar year Individual deductible was not satisfied when these claims processed and so no
payment was made by usDue to the fact you received this care, we are unable to waive your member financial
responsibilityTherefore, the deductible on the above mentioned claims remains your member financial
responsibility
Please note we reviewed all of your claim history and determined that any routine office visit that had a primary
diagnosis of supervision of a pregnancy was paid In full of the allowable expense as per your benefits for
prenatal care
While we understand your request to not be held financially responsible for the services based on the wording
you reflect on your benefit summary, as a health Insurance plan, all benefits are provided in accordance with the
certificate In effect at the time the services are renderedIn the future, you may contact our Customer Care
representatives prior to any needed service for a full benefit quote to avoid any unexpected expenses
We appreciate your concerns and the time you have taken to communicate with usWe continue to seek ways to
improve our process and the quality of service that we provide to our members and appreciate you bringing this
matter to our attentionWe have forwarded your concerns regarding the benefit wording to the appropriate
departments for consideration
We trust our explanation for our decision is helpful in understanding the provisions of your policyFor additional
information regarding your benefits for which this decision was made, please refer to the following sections of
your certificate:
Section I- Definitions
Section IV- Cost-Sharing Expenses and Allowed Amount
Section IX- Outpatient and Professional Services
Section XXVIII- Schedule of Benefits
If you disagree with this determination, you have options available to youPlease refer to the enclosed
Information Sheet describing important information about your rights
If you have any questions, please call the number on the back of your Identification card or contact us at the
following address and telephone number:
Advocacy Department
P.OBox
Syracuse, New York ***
*** (Fax)

We have researched this and responded to our member. Pleaes be advised that the PHI form provided to us by you was for *** ** ***. In order to release the outcome of this inquiry to you, we will be
need a PHI form for *** ** *** I have attached a new PHI form. Thank you

"Due to privacy laws, the business has sent a reply directly to the consumer."

Please note that this complaint has been received by Excellus Health Plan and is currently in process. The attached privacy forms are both incomplete. We have issued out a privacy form to our member to complete if they wish. Thank you, Amy C*** ###-###-####

We recently received an inquiry from you regarding the processing of the above referenced claim. We have completed our review and have concluded that our determination should be reversed with respect to the above serviceThe claim will be adjusted to be processed with Mr***' group's
Level One Preferred Network benefit in effect at the time services are renderedHe may remain financially responsible for any applicable copayments, coinsurances and deductibles. If Mr*** has any questions, he may contact our off directly at the following address or telephone number:

Due to privacy laws, the business has sent a reply directly to the consumer

See attached response

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.I have no problem filling that...

formbout BUT THEY FAED TO MAIL YOU THE LETER THAT STATES WHAT THEY ARE WILLING TO PAY FOR. IN WHICH THEY JUST MAILED ME DATES AUGUST 22 2014 NOTE A YR AGO. SAME LETTER THAT THEY MAILED SUMMIT DENTAL STATED WHAT THEY WOULD PAY FOR. IF I COULD GET A FAX NUMBER I CAN FAX AND HIGHLIGHT IT AND YOU CAN SEE FOR YOURSELF. THEY ARE JUST PRONGING IT.O
Regards,
[redacted]

Attached please find the requested Excellus HIPAA form.