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Fallon Community Health Plan, Inc.

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Reviews Fallon Community Health Plan, Inc.

Fallon Community Health Plan, Inc. Reviews (2)

For 4 months my son has been declined mental health services for ADHD and communication. This is an ongoing issue. Fallon/ [redacted] have ignorged me.I am a Federal employee working for the [redacted]. I have 20 years of service. My son and I have Fallon Community Health Plan and [redacted] handles the mental health portion. My son has ADHD, PTSD and communication difficulties. He has been in therapy since he was 6 or 7. I have always had problems with finding a provider for my son with Fallon. Currenly he is in need of a therapist, psychiatrist and a behavioral intervention. In the past he has had individual therapy, family therapy, in home family therapy and a psychiatrist. ** were getting services with [redacted] Mental Health and they, [redacted] Health cut our services. I filed a grievance through Fallon around February 2014 and nothing was done. Basically they just told me [redacted] Health's ([redacted]) side of the story. They failed to mention many key factors. So Fallon and [redacted] begin assissting me with finding a new mental health team at the end of February or early April 2014. My son has not had the services that he needs since February 2014. So from February 2014 until now he has been denied services. Everytime I call either [redacted] or Fallon, I am told that they are working on getting my son a provider. They say should be expecting a call for an intake. I am getting nowhere and need some help. My son is not doing well in school and could possibly get kept back. This hardship has caused alot of distress in school and in the home for [redacted], myself, my [redacted] and school staff members. I pay for health insurance but I am unable to access services. Please advise.Desired SettlementI am seeking $1,477.72 which is what I paid for 4 months of services which I did not receive.Business Response Fallon Health and [redacted] have made many attempts to resolve the issues for Ms. [redacted]. [redacted] has been in contact with the provider that her son was seeing and they have reported that the member was not willing to engage in changing her parenting skills, which is crucial for successful treatment of her son.Based on [redacted] findings in the grievance review - they have made many outreach phone calls to Ms. [redacted] and many of them go unanswered. [redacted] outreached to Ms. [redacted] on 6/13 with no return calls. [redacted] thought it might be best that if Ms. [redacted] contacts Fallon Health or [redacted] to complain about services or lack thereof, to try and set up a conference call between the member, [redacted] and FCHP or if it is a specific complaint against a provider that [redacted], the member and the provider would try and have a conference call to discuss. On 6/13 Ms. [redacted] requested all her grievance information from all grievances be sent to her from this year as she was taking this to her ** department. A closed letter was drafted and all of this was faxed to Ms. [redacted] on the 16th. Ms. [redacted] did not agree with the response and wanted all information changed as she said it was inaccurate. She called and spoke with both representatives of Fallon Health, and it was explained ** could not put information into her close letter that ** did not have and that ** cannot pick a side when it was a he said/she said complaint. The representatives from Fallon Health tried to explain to her that [redacted] is trying to actively work with her but she needs to return their calls to have services set up. At this point she told Fallon Health she did not want any more phone calls from anyone that her ** department is handling it.Consumer Response My son does not receive any mental health services. I pay my health insurance as directed by law and my son's mental health is being neglected. I need this case to be reopened. I have not been provided with any parenting classes or behavior modification support as claimed in their response. In fact, I have asked for that type of support numerous times over the course of my enrollment. I have been told that I am not authorized such services because I do not have the MassHealth which was left out of their claim. Bottom line is Tiwan does not have mental health services and they have been null and void for months. There are false accusations about me and my parenting abilities which has nothing to do with providing services to my son and to myself. Please re-open the case and lets focus on the facts: 1. What mental health services have been provided to Tiwan?2. I have paid for services that I do not receive. I deserve reimbursement for that reason. I am not sure how the case was closed and the issues are still standing Please let me know if you need anything else from me to re-open this case. I appreciate you efforts in this matter. Sincerly, [redacted] Business Response Fallon Health and [redacted] do show this member's son having 13 appointments from 1/7/14-3/27/14. There was another authorization in place for the child to receive services until 5/20/14 but no additional dates of service have been billed to [redacted] after 3/27/14. ** show another authorization in place for services in Allston Massachusetts since 6/13/14 but ** do not show any visits being used at this time.The member is requesting that Fallon Health reimburses her for her health care premiums. The member has had services in 2014 and there are open authorizations for the child to receive services if the mother so chooses. Fallon Health will not be reimbursing for her insurance premiums.The member does need to contact [redacted] as previously instructed to ensure her son receives the care she is requesting.Consumer Response (The consumer indicated he/she DID NOT accept the response from the business.)My son still does not have any mental health care.I want reimbursement for $1,477.72 Only 1 mental health service provider contacted me about 1 week ago and said they could set me up with services in 2 months.Let's settle this and move on. Business Response [redacted] has supplied multiple options for contracted providers. ** must adhere to those providers schedules for appointment availability. Mental Health providers often require that your treatment start with a Psychologist and when a treatment plan and an appointment is available they will have you see a Psychiatrist if needed. A monthly premium is made to ensure coverage of any medical treatment. The monthly premium is the amount charged by Fallon for the coverage provided under your contract. During the four months in question, your son was fully covered by his medical insurance. As such, your monthly premium charge was appropriate. Consumer Response (The consumer indicated he/she DID NOT accept the response from the business.)My son was not authorized mental health services for over 4 months. My family was left in crisis. Whatever you feel is a reasonable amount of reimbursement should be offered. [redacted] Counseling finally called last month to offer services to my son but said it would another 2 months before he would be seen for intake. The fact still exists that there were no mental health services authorized for the last 4 or so months.I believe I should be reimbursed. Not only does it seem that you are unwilling to do but you are also negating the fact that there was a lapse in service. I am dissatisfied with you actions and your response.

FALLON NOT COVERING ANESTESIA FOR FIRST TIME PREVENTATIVE COLONOSCOPY. OTHER TYPE MEDICATION DID NOT WORK THE FIRST TIME.I turned 50 years old in November so I figured that since this insurance plan is supposed to cover the entire cost of a colonoscopy that I would have the preventative maintenance test done even though I am not experiencing any issues.I went to the gastrointestinologist and made the appointment for the colonoscopy.At my appointment I was told that the insurance company (Fallon) would only cover versa type drugs for the procedure and I was fine with that. During the procedure I seemed to be too alert, (even though I felt totally out of it and don't remember a thing), and the doctor was unable to perform the colonoscopy because I kept tensing up and he could not get the tool through without hurting or injuring me.In recovery I was informed of this and told they would get in touch with my insurance company (Fallon) and see if they would okay the anesthesia since that is what I would need to put me out enough to be able to have the colonoscopy done.I received a phone call a month later saying that the insurance company (Fallon) okayed the anesthesia and made another appointment. The week before the hospital called me and told me that I had to have $500 for the procedure because Fallon did not cover the anesthesia and that I had not reached my deductible. So I cancelled because I cannot afford that. The point is that Fallon states that they cover the colonoscopy at 50 years of age because it is preventative and it should not matter what kind of medicine I need to put me out in order to perform it.Desired SettlementI want the insurance company (Fallon) to cover the cost of this preventative test and the cost of the anesthesia.Business Response Fallon Health covers twilight sedation in full during preventive colonoscopies. Any other anesthesia required for a colonoscopy requires a prior authorization by the health plan and is subject to deductibles/co-insurance. The anesthesia claim received by Fallon Health applied $4.67 to the member's deductible for non twilight sedation.All services for preventive colonoscopies are covered unless a member has anesthesia services other than twilight sedation.Final Consumer Response (The consumer indicated he/she DID NOT accept the response from the business.)I don't have a choice but to accept it but their policy is not moral or responsible. I will advocate their poor policies to the public every chance I get.

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Description: Insurance Services, Insurance Services – Commercial, Insurance-Health, Health Maintenance Organizations

Address: 10 Chestnut St, Worcester, Massachusetts, United States, 01608-2810

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