Complaint: [redacted] I am rejecting this response because: I'm not sure where HMSA's Legal Affairs Dept is getting their informationSo let's start with the 2nd paragraph when she states "the claims were delayed due to no signature"Where did this storyline come from? This is a complete lie, and have no idea where/how HMSA concocted this informationI submitted all intl claims online and can access all submitted claims via their archived claim systemALL claims were digitally signed, and NEVER were any claims returned to me on Jan 30, due to no signature, because they WERE ALL SIGNEDIf HMSA's Legal Affairs dept would like, I will provide them with my online user name and password so that I can prove that all claims were submitted appropriately and digitally signedWhere did you even come up with this? For their 3rd paragraph, yes HMSA has mailed me check in the past weeksThanks for thatIt only took them monthsNothing to really be boasting aboutAlso, they mention the Member's final claim was processed....actually noI still have claims that are still in the appeal process that I have not been paid on, and one claim that HMSA has not paid on due to needing more informationIronic on this claim, as they paid a % of the surgery, but at this point are denying the anesthesiologist claimThey are requesting proof that his services were neededI guess you're supposed to have surgery without anesthesia?? So using the term "final payment has been made", implying that HMSA has fulfilled their requirement of paying on all my claims is not an accurate statement For the fourth paragraph "HMSA did not receive the claim documents until Aug 24"This is another complete lieThe first time the claims were sent to HMSA on May 25th at 9:12am to [redacted] , with my assigned ref case # [redacted] My last sentence of that email said if there were any questions to please contact meAfter weeks with no acknowledgement, I sent a follow up email (attached to the original email) on June 9th at 12:27pm stating, "can someone please confirm that this email was received" Again no correspondence from HMSAI then called the customer service line and spoke with Kristine who said she saw the emails but didn't see any claims attachedI asked how come no one responded back that there were no claims attached, she requested I send them againSo I sent a 3rd email with the claims attached on June 13th at 6:28pmI then followed up with a couple calls after that and actually on July 8th was told my claims were being reviewed and processedI then sent a 4th email on August 8th at 2:42pm following up on the previous emailsAgain, no response from anyoneI called back on Aug 15th and was told that all the claims had been "assigned" to a claims adjuster at the end of JulyAgain, I still wasn't seeing any payments from HMSA and called again and was finally told by a CS agent that she wanted to get my case up to higher mgmt and I was put in contact with a Claims Manager David A***, who asked me once again to forward the claims, since they had no record of them - so I did so on August 22nd at 2:15amHe suggested that since the files were large they might not have come thru, but I asked why then did no one contact me to have them resent and why would the CS agents say they were received and being processed? He had no answer for thatBefore telling lies, it might be prudent for HMSA to ask their IT department to pull emails from their server just to make sure that what they are going to be putting in an official document is trueEverything I have said is true, and I have the emails to prove itOnce again, as I mentioned in my first letterI can provide copies of all email correspondence I have sent to HMSA For the 5th paragraph, she seems to imply that I have been unresponsive to emails /phone callsAgain incorrectI have responded to ALL emails that the [redacted] department has sent to meI have copies of all those emails tooI received only one voicemail on my cell phone on Oct 31st, at the time I was deployed to help out with the Hurricane relief efforts and was working out of a temporary office, with a temp phone, but I returned the phone call within the hour and spoke with the agentI did mention that he could call me back on that number if he had further questions since at the time I was stateside, and that way he didn't have to call my German cell phone numberA couple weeks later he must have given my number to his colleague as a way to contact me, but by that time I had deployed to Puerto Rico for Hurricane work and no longer had access to that phoneSo yes, it was not possible to contact me on Nov 17th at that phone, sorry that HMSA had to leave voicemailsNor did I respond to the email sent on the 17th either, as I was in a country with little electricity and spotty internet connection, sorry but there were higher priorities going onIf HMSA had paid the claims on a timely basis, and would finish paying the outstanding claims, we would not be having to have phone/email discussions months laterAnd yes, as of their letter on 20th Nov, I hadn't responded to their email, BUT when I arrived back to Germany on the 20th, and checked my emails on the 21st, I did respond back to MsG***So please don't imply that I am unresponsive, its an insult Truthfully, the only response HMSA should be giving me is "sorry, we and [redacted] have messed up, there's no reason this should be taking so long, and we'll fix it"I don't need the Legal Affairs Dept creating falsehoods and trying to cover themselves, acting like they are trying to cover themselves for a lawsuitI just want HMSA to pay my claimsI pay for health insurance every month out of my federal paycheck and in return when I require healthcare services I expect my insurance company to stand up and do their jobI expected way more out of HMSA Sincerely, [redacted] ***
From: Cat C*** [mailto:Cat_***@hmsa.com] Sent: Friday, January 20, 10:AMTo: complaints Cc: Elisa Y*** ; Kimberly J*** Subject: Response to Member Complaint ID# ***Attached please find
HMSA’s response to Dawn B***’s January 11, complaintIf you have any questions or concerns, please do not hesitate to contact me for clarification.Thank you!
We are writing in response to the additional information your office received from our Memberregarding a complaint you assigned ID number *** You requested that we review the Member’scomments and respond to your office by November 20, This letter is HMSA’s response to the Member’scomments.Regarding the delay in processing the Member’s claims, our international assistance vendor returnedsome of the Member’s claims to her because there was no signature on the documents submittedThe claimswere returned via our Member’s email address on January 30, 2017.HMSA did not receive the claims documents until August 24, 2017, when our Member emailed them toour Claims ManagerSince then, the claims have been translated, coded, and processedHMSA has sent themember two checks thus farA check for $was mailed on November 8, and a check for $1,wasmailed on November 16, The Member’s final claim was processed on November 15, and paymentin the amount of $will be issued this week.Regarding HMSA’s communication with the Member, once the Member filed appeals regarding herclaims, HMSA’s Member Advocacy and Appeals Department (MAA) became her point of contactIt is moreefficient and leaves less room for miscommunication when there is a single point of contact for the Member.MAA contacted the Member via email on at least three occasionsThey also left at least three voicemailmessages for her on the number where she requested to receive telephone callsA MAA Case ResolutionSpecialist sent the Member an email on November 17, asking if there was a better telephone number atwhich to reach herAs of the date of this letter, the MAA Case Resolution Specialist has received no responsefrom the Member
We are writing in response to the October16, complaint to your office, to which you assigned ID number ***You requested that we review the Member's concernsand respond to your office regarding those concerns by October 30, This letter is HMSA's response to the Member's
concerns.HMSA regrets this Member's experienceHMSA has investigated the Member's concerns,including listening to the telephone call in questionWhile the HMSA representative had the Member's best interests at heart, his handling of the call was not idealThat
representative has received coaching on how to better handle such situations in the future.Additionally, the representative's entire unit received a refresher as to how such situations should be handledHMSA has shared the above information with the Member.Please feel free to call me at *** should you have any questions regarding this matter
Complaint: ***
I am rejecting this response because: In response to MsCharpie's (Legal Affairs) letter:
1) Regarding the "complicating factor that services were provided in Germany" Is *** not an International Company? I was told by HMSA to file all my claims on the *** international website, ***, so obviously there is a process in place when one is provided services outside of HawaiiHow is this complicated? The second complication HMSA states is that "medical records are in German"Not sure how that is a complication either, due to the fact that *** *** *** told me that they translate all international claims, before sending to the local *** providerIf anything was left un-translated, can HMSA not figure out how to translate a foreign languageThere is always *** ***, plus I thought they don't "discriminate," based on languageDoes it take 8-months to translate from German to English? She also states the hour time difference makes communication difficultThis is not an issueFirst of all, email is not constricted due to time differenceAt the beginning, I had suggested that email was a better form of communication due to the time difference and the fact that I would be charged international phone rates, but as this has dragged on and I wanted to actually speak with someone, I have told them to call meI have several emails that I can provide where I state that, and I have called MrA*** on his office line leaving a message to call me directly at any time of day to get this resolvedHe has yet to return my callI'm sure your IT dept could check his phone records to prove that I have tried to make contactThere is only a 12-hour time difference, so if they called at 8am, it would only be 8p at night for me, so communication is not difficult
2) Regarding the $adjustment, I did finally call *** myself this week and we figured out the issue, so yes, for that particular claim we are doneBut do note, this claim was filed on Jan So for a simple $Emergency Room visit where I went for a broken wrist, it took HMSA Months to pay the claim
How can HMSA state, "the remainder of the members claims are still being processed" How long does it take? These claims are for a simple broken wrist and the subsequent surgery to put a plate in, and follow up Physical Therapy visitsThese claims cannot be that difficult
3) There has only been "one" request for me to get doctor notes and that was for the physical therapyThe appeal specialist requested notes due to service dates being inaccurate on the claimBut as my appeal noted, the treatment dates were inputted incorrectly by ***, not by anything I had providedAnd I have requested the German physical therapy provider doctor notes, but as of yet have not received themEvery other request for information has been provided
4) HMSA states they in "continual contact with the member in hopes of obtaining information or being able to resolve the appeals." This is completely falseI do not believe that Legal Affairs has been given the "truth" by the HMSA staff on their communication with meThe last email I received from the claims manager was August(months ago) I have sent several follow up emails trying to get a resolution date and there has been no response, which was the whole point of me elevating this claim to the Revdex.comIf HMSA would have been communicating with me and would have resolved claims, I would not have filed this complaintIf the department would like me to provide a timeline and email trail to prove the gross negligence in my insurance claim processing, I would be happy to provide that, anything to get my claims processed and for me to be reimbursed what I'm entitled to
Sincerely,
*** ***
We are writing in response to the October 11, 2017 complaint to your office, to which you assigned ID number [redacted]. You requested that we review the Member's concernsand respond to your office regarding those concerns by October 25, 2017. This letter is HMSA's response to the Member's...
concerns.HMSA has been working diligently to assist this Member to get her claims paid. The complicating factors are that the services were provided in Germany,the medical records are mostly in German,and the 13-hour time difference between the Member/providers and HMSA, which makes communication difficult.HMSA has processed the $175 adjustment referenced in the Member's complaint and the Member should have received that payment via wire transfer to her account by September 18, 2017. Two additional claims have been adjusted, and payment for these claims is being directed to the Member through a wire transfer from [redacted]. The remainder of the Member's claims are still being processed,and payment for these claims will be sent directly from HMSA.Regarding the Member's statement that "of the several claims that have been processed, they have usually been paid out incorrectly," HMSA is in the process of reviewing the Member's
appeals regarding the level of reimbursement she has received. The Specialists assigned to the Member's appeals have requested additional information that is necessary to process her appeals from the Member.As of the date of this response, HMSA has not received the additional information but is in continual contact with the Member in hopes of obtaining the information or otherwise being able to resolve the Member's appeals.
Complaint: [redacted]
I am rejecting this response because:
I'm not sure where HMSA's Legal Affairs Dept is getting their information. So let's start with the 2nd paragraph when she states "the claims were delayed due to no signature". Where did this storyline come from? This is a complete lie, and have no idea where/how HMSA concocted this information. I submitted all intl claims online and can access all submitted claims via their archived claim system. ALL claims were digitally signed, and NEVER were any claims returned to me on Jan 30, due to no signature, because they WERE ALL SIGNED. If HMSA's Legal Affairs dept would like, I will provide them with my online user name and password so that I can prove that all claims were submitted appropriately and digitally signed. Where did you even come up with this?
For their 3rd paragraph, yes HMSA has mailed me 2 check in the past 2 weeks. Thanks for that. It only took them 10 months. Nothing to really be boasting about. Also, they mention the Member's final claim was processed....actually no. I still have 3 claims that are still in the appeal process that I have not been paid on, and one claim that HMSA has not paid on due to needing more information. Ironic on this claim, as they paid a % of the surgery, but at this point are denying the anesthesiologist claim. They are requesting proof that his services were needed. I guess you're supposed to have surgery without anesthesia?? So using the term "final payment has been made", implying that HMSA has fulfilled their requirement of paying on all my claims is not an accurate statement.
For the fourth paragraph "HMSA did not receive the claim documents until Aug 24". This is another complete lie. The first time the claims were sent to HMSA on May 25th at 9:12am to [redacted], with my assigned ref case # [redacted]. My last sentence of that email said if there were any questions to please contact me. After 2 weeks with no acknowledgement, I sent a follow up email (attached to the original email) on June 9th at 12:27pm stating, "can someone please confirm that this email was received" Again no correspondence from HMSA. I then called the customer service line and spoke with Kristine who said she saw the emails but didn't see any claims attached. I asked how come no one responded back that there were no claims attached, she requested I send them again. So I sent a 3rd email with the claims attached on June 13th at 6:28pm. I then followed up with a couple calls after that and actually on July 8th was told my claims were being reviewed and processed. I then sent a 4th email on August 8th at 2:42pm following up on the previous emails. Again, no response from anyone. I called back on Aug 15th and was told that all the claims had been "assigned" to a claims adjuster at the end of July. Again, I still wasn't seeing any payments from HMSA and called again and was finally told by a CS agent that she wanted to get my case up to higher mgmt and I was put in contact with a Claims Manager David A[redacted], who asked me once again to forward the claims, since they had no record of them - so I did so on August 22nd at 2:15am. He suggested that since the files were large they might not have come thru, but I asked why then did no one contact me to have them resent and why would the CS agents say they were received and being processed? He had no answer for that. Before telling lies, it might be prudent for HMSA to ask their IT department to pull emails from their server just to make sure that what they are going to be putting in an official document is true. Everything I have said is true, and I have the emails to prove it. Once again, as I mentioned in my first letter. I can provide copies of all email correspondence I have sent to HMSA.
For the 5th paragraph, she seems to imply that I have been unresponsive to emails /phone calls. Again incorrect. I have responded to ALL emails that the [redacted] department has sent to me. I have copies of all those emails too. I received only one voicemail on my cell phone on Oct 31st, at the time I was deployed to help out with the Hurricane relief efforts and was working out of a temporary office, with a temp phone, but I returned the phone call within the hour and spoke with the agent. I did mention that he could call me back on that number if he had further questions since at the time I was stateside, and that way he didn't have to call my German cell phone number. A couple weeks later he must have given my number to his colleague as a way to contact me, but by that time I had deployed to Puerto Rico for Hurricane work and no longer had access to that phone. So yes, it was not possible to contact me on Nov 17th at that phone, sorry that HMSA had to leave 3 voicemails. Nor did I respond to the email sent on the 17th either, as I was in a country with little electricity and spotty internet connection, sorry but there were higher priorities going on. If HMSA had paid the claims on a timely basis, and would finish paying the outstanding claims, we would not be having to have phone/email discussions 10 months later. And yes, as of their letter on 20th Nov, I hadn't responded to their email, BUT when I arrived back to Germany on the 20th, and checked my emails on the 21st, I did respond back to Ms. G[redacted]. So please don't imply that I am unresponsive, its an insult.
Truthfully, the only response HMSA should be giving me is "sorry, we and [redacted] have messed up, there's no reason this should be taking so long, and we'll fix it". I don't need the Legal Affairs Dept creating falsehoods and trying to cover themselves, acting like they are trying to cover themselves for a lawsuit. I just want HMSA to pay my claims. I pay for health insurance every month out of my federal paycheck and in return when I require healthcare services I expect my insurance company to stand up and do their job. I expected way more out of HMSA.
Sincerely,
[redacted]
We are writing in response to the September 15, 2017 complaint to your office, to which you assigned ID number [redacted]. You requested that we review the Member's concernsand respond to your office regarding those concerns by October 10, 2017. This letter is HMSA's response to the...
Member'sconcerns.HMSA apologizes for its delay in resolving this Member's issue.There are many "moving parts" that have been complicating resolution of the Member's claims. What HMSA received from the Member on
June 12, 2017 was not a claim form, but rather an itemized
invoice. HMSA sent that invoice via a claim misroute process to [redacted] of Minnesota. HMSA did so because [redacted] Clinic is a
contracted provider with that plan and
HMSA honors any contractual requirements between the provider and the local plan, such as payment direction and fee schedules. [redacted] of Minnesota informed HMSA that it could not send HMSA the information required because the invoice was missing the diagnosis codes and place of service.HMSA asked [redacted] of Minnesota to have [redacted] Clinic submit a
claim to [redacted] of Minnesota, which would Include the missing information needed to process the Member's reimbursement. Mayo Clinic informed HMSA that the Member did not provide the complete subscriber identification number.This prevented [redacted] Clinic from submitting a claim for processing. HMSA has provided [redacted] Clinic the complete identification number, and [redacted] Clinic has agreed to submit a claim to [redacted] of Minnesota.. Additionally, because the member is an HMO member, his benefits do not include coverage for services received outside of his health center unless the services are urgent or emergent, or unless his primary care physician first submits a referral for approval. HMSA is in the processo f confirming with the member's PCP that he referred the member to [redacted] Clinic for
the services at issue.Further complicating the issue is the fact that HMSA is the member's secondary coverage. The member's primary coverage is [redacted], provided through a plan by [redacted]. Therefore, his HMSA plan needs to be coordinated with his coverage with [redacted] before the member's reimbursement can be processed. The documentation the member provided HMSAdoes not containthe member's Explanation of Benefits for the receivedservices, only screenshots of claims. These screenshots only reflect no financial responsibility by the member, and does not include the total charge, description of the services,or the amount that [redacted] paid for those services. HMSA needs this information to coordinate benefits with [redacted]. We have confirmed with [redacted] Clinic that they will provide us the primary payer information with their claim so that we can coordinate benefits.An HMSA Manager spoke to the member on October 6, 2017 to explain the steps HMSA is
taking to resolve his complaint. The member expressed understanding of the steps HMSA is taking to resolve his concerns and was pleased that HMSA provided him with an update.matter.Please feel free to call me at [redacted] should you have any questions regardingthis
Complaint: [redacted] I am rejecting this response because: I'm not sure where HMSA's Legal Affairs Dept is getting their informationSo let's start with the 2nd paragraph when she states "the claims were delayed due to no signature"Where did this storyline come from? This is a complete lie, and have no idea where/how HMSA concocted this informationI submitted all intl claims online and can access all submitted claims via their archived claim systemALL claims were digitally signed, and NEVER were any claims returned to me on Jan 30, due to no signature, because they WERE ALL SIGNEDIf HMSA's Legal Affairs dept would like, I will provide them with my online user name and password so that I can prove that all claims were submitted appropriately and digitally signedWhere did you even come up with this? For their 3rd paragraph, yes HMSA has mailed me check in the past weeksThanks for thatIt only took them monthsNothing to really be boasting aboutAlso, they mention the Member's final claim was processed....actually noI still have claims that are still in the appeal process that I have not been paid on, and one claim that HMSA has not paid on due to needing more informationIronic on this claim, as they paid a % of the surgery, but at this point are denying the anesthesiologist claimThey are requesting proof that his services were neededI guess you're supposed to have surgery without anesthesia?? So using the term "final payment has been made", implying that HMSA has fulfilled their requirement of paying on all my claims is not an accurate statement For the fourth paragraph "HMSA did not receive the claim documents until Aug 24"This is another complete lieThe first time the claims were sent to HMSA on May 25th at 9:12am to [redacted] , with my assigned ref case # [redacted] My last sentence of that email said if there were any questions to please contact meAfter weeks with no acknowledgement, I sent a follow up email (attached to the original email) on June 9th at 12:27pm stating, "can someone please confirm that this email was received" Again no correspondence from HMSAI then called the customer service line and spoke with Kristine who said she saw the emails but didn't see any claims attachedI asked how come no one responded back that there were no claims attached, she requested I send them againSo I sent a 3rd email with the claims attached on June 13th at 6:28pmI then followed up with a couple calls after that and actually on July 8th was told my claims were being reviewed and processedI then sent a 4th email on August 8th at 2:42pm following up on the previous emailsAgain, no response from anyoneI called back on Aug 15th and was told that all the claims had been "assigned" to a claims adjuster at the end of JulyAgain, I still wasn't seeing any payments from HMSA and called again and was finally told by a CS agent that she wanted to get my case up to higher mgmt and I was put in contact with a Claims Manager David A***, who asked me once again to forward the claims, since they had no record of them - so I did so on August 22nd at 2:15amHe suggested that since the files were large they might not have come thru, but I asked why then did no one contact me to have them resent and why would the CS agents say they were received and being processed? He had no answer for thatBefore telling lies, it might be prudent for HMSA to ask their IT department to pull emails from their server just to make sure that what they are going to be putting in an official document is trueEverything I have said is true, and I have the emails to prove itOnce again, as I mentioned in my first letterI can provide copies of all email correspondence I have sent to HMSA For the 5th paragraph, she seems to imply that I have been unresponsive to emails /phone callsAgain incorrectI have responded to ALL emails that the [redacted] department has sent to meI have copies of all those emails tooI received only one voicemail on my cell phone on Oct 31st, at the time I was deployed to help out with the Hurricane relief efforts and was working out of a temporary office, with a temp phone, but I returned the phone call within the hour and spoke with the agentI did mention that he could call me back on that number if he had further questions since at the time I was stateside, and that way he didn't have to call my German cell phone numberA couple weeks later he must have given my number to his colleague as a way to contact me, but by that time I had deployed to Puerto Rico for Hurricane work and no longer had access to that phoneSo yes, it was not possible to contact me on Nov 17th at that phone, sorry that HMSA had to leave voicemailsNor did I respond to the email sent on the 17th either, as I was in a country with little electricity and spotty internet connection, sorry but there were higher priorities going onIf HMSA had paid the claims on a timely basis, and would finish paying the outstanding claims, we would not be having to have phone/email discussions months laterAnd yes, as of their letter on 20th Nov, I hadn't responded to their email, BUT when I arrived back to Germany on the 20th, and checked my emails on the 21st, I did respond back to MsG***So please don't imply that I am unresponsive, its an insult Truthfully, the only response HMSA should be giving me is "sorry, we and [redacted] have messed up, there's no reason this should be taking so long, and we'll fix it"I don't need the Legal Affairs Dept creating falsehoods and trying to cover themselves, acting like they are trying to cover themselves for a lawsuitI just want HMSA to pay my claimsI pay for health insurance every month out of my federal paycheck and in return when I require healthcare services I expect my insurance company to stand up and do their jobI expected way more out of HMSA Sincerely, [redacted] ***
From: Cat C*** [mailto:Cat_***@hmsa.com] Sent: Friday, January 20, 10:AMTo: complaints Cc: Elisa Y*** ; Kimberly J*** Subject: Response to Member Complaint ID# ***Attached please find
HMSA’s response to Dawn B***’s January 11, complaintIf you have any questions or concerns, please do not hesitate to contact me for clarification.Thank you!
We are writing in response to the additional information your office received from our Memberregarding a complaint you assigned ID number *** You requested that we review the Member’scomments and respond to your office by November 20, This letter is HMSA’s response to the Member’scomments.Regarding the delay in processing the Member’s claims, our international assistance vendor returnedsome of the Member’s claims to her because there was no signature on the documents submittedThe claimswere returned via our Member’s email address on January 30, 2017.HMSA did not receive the claims documents until August 24, 2017, when our Member emailed them toour Claims ManagerSince then, the claims have been translated, coded, and processedHMSA has sent themember two checks thus farA check for $was mailed on November 8, and a check for $1,wasmailed on November 16, The Member’s final claim was processed on November 15, and paymentin the amount of $will be issued this week.Regarding HMSA’s communication with the Member, once the Member filed appeals regarding herclaims, HMSA’s Member Advocacy and Appeals Department (MAA) became her point of contactIt is moreefficient and leaves less room for miscommunication when there is a single point of contact for the Member.MAA contacted the Member via email on at least three occasionsThey also left at least three voicemailmessages for her on the number where she requested to receive telephone callsA MAA Case ResolutionSpecialist sent the Member an email on November 17, asking if there was a better telephone number atwhich to reach herAs of the date of this letter, the MAA Case Resolution Specialist has received no responsefrom the Member
We are writing in response to the October16, complaint to your office, to which you assigned ID number ***You requested that we review the Member's concernsand respond to your office regarding those concerns by October 30, This letter is HMSA's response to the Member's
concerns.HMSA regrets this Member's experienceHMSA has investigated the Member's concerns,including listening to the telephone call in questionWhile the HMSA representative had the Member's best interests at heart, his handling of the call was not idealThat
representative has received coaching on how to better handle such situations in the future.Additionally, the representative's entire unit received a refresher as to how such situations should be handledHMSA has shared the above information with the Member.Please feel free to call me at *** should you have any questions regarding this matter
Complaint: ***
I am rejecting this response because: In response to MsCharpie's (Legal Affairs) letter:
1) Regarding the "complicating factor that services were provided in Germany" Is *** not an International Company? I was told by HMSA to file all my claims on the *** international website, ***, so obviously there is a process in place when one is provided services outside of HawaiiHow is this complicated? The second complication HMSA states is that "medical records are in German"Not sure how that is a complication either, due to the fact that *** *** *** told me that they translate all international claims, before sending to the local *** providerIf anything was left un-translated, can HMSA not figure out how to translate a foreign languageThere is always *** ***, plus I thought they don't "discriminate," based on languageDoes it take 8-months to translate from German to English? She also states the hour time difference makes communication difficultThis is not an issueFirst of all, email is not constricted due to time differenceAt the beginning, I had suggested that email was a better form of communication due to the time difference and the fact that I would be charged international phone rates, but as this has dragged on and I wanted to actually speak with someone, I have told them to call meI have several emails that I can provide where I state that, and I have called MrA*** on his office line leaving a message to call me directly at any time of day to get this resolvedHe has yet to return my callI'm sure your IT dept could check his phone records to prove that I have tried to make contactThere is only a 12-hour time difference, so if they called at 8am, it would only be 8p at night for me, so communication is not difficult
2) Regarding the $adjustment, I did finally call *** myself this week and we figured out the issue, so yes, for that particular claim we are doneBut do note, this claim was filed on Jan So for a simple $Emergency Room visit where I went for a broken wrist, it took HMSA Months to pay the claim
How can HMSA state, "the remainder of the members claims are still being processed" How long does it take? These claims are for a simple broken wrist and the subsequent surgery to put a plate in, and follow up Physical Therapy visitsThese claims cannot be that difficult
3) There has only been "one" request for me to get doctor notes and that was for the physical therapyThe appeal specialist requested notes due to service dates being inaccurate on the claimBut as my appeal noted, the treatment dates were inputted incorrectly by ***, not by anything I had providedAnd I have requested the German physical therapy provider doctor notes, but as of yet have not received themEvery other request for information has been provided
4) HMSA states they in "continual contact with the member in hopes of obtaining information or being able to resolve the appeals." This is completely falseI do not believe that Legal Affairs has been given the "truth" by the HMSA staff on their communication with meThe last email I received from the claims manager was August(months ago) I have sent several follow up emails trying to get a resolution date and there has been no response, which was the whole point of me elevating this claim to the Revdex.comIf HMSA would have been communicating with me and would have resolved claims, I would not have filed this complaintIf the department would like me to provide a timeline and email trail to prove the gross negligence in my insurance claim processing, I would be happy to provide that, anything to get my claims processed and for me to be reimbursed what I'm entitled to
Sincerely,
*** ***
We are writing in response to the October 11, 2017 complaint to your office, to which you assigned ID number [redacted]. You requested that we review the Member's concernsand respond to your office regarding those concerns by October 25, 2017. This letter is HMSA's response to the Member's...
concerns.HMSA has been working diligently to assist this Member to get her claims paid. The complicating factors are that the services were provided in Germany,the medical records are mostly in German,and the 13-hour time difference between the Member/providers and HMSA, which makes communication difficult.HMSA has processed the $175 adjustment referenced in the Member's complaint and the Member should have received that payment via wire transfer to her account by September 18, 2017. Two additional claims have been adjusted, and payment for these claims is being directed to the Member through a wire transfer from [redacted]. The remainder of the Member's claims are still being processed,and payment for these claims will be sent directly from HMSA.Regarding the Member's statement that "of the several claims that have been processed, they have usually been paid out incorrectly," HMSA is in the process of reviewing the Member's
appeals regarding the level of reimbursement she has received. The Specialists assigned to the Member's appeals have requested additional information that is necessary to process her appeals from the Member.As of the date of this response, HMSA has not received the additional information but is in continual contact with the Member in hopes of obtaining the information or otherwise being able to resolve the Member's appeals.
Complaint: [redacted]
I am rejecting this response because:
I'm not sure where HMSA's Legal Affairs Dept is getting their information. So let's start with the 2nd paragraph when she states "the claims were delayed due to no signature". Where did this storyline come from? This is a complete lie, and have no idea where/how HMSA concocted this information. I submitted all intl claims online and can access all submitted claims via their archived claim system. ALL claims were digitally signed, and NEVER were any claims returned to me on Jan 30, due to no signature, because they WERE ALL SIGNED. If HMSA's Legal Affairs dept would like, I will provide them with my online user name and password so that I can prove that all claims were submitted appropriately and digitally signed. Where did you even come up with this?
For their 3rd paragraph, yes HMSA has mailed me 2 check in the past 2 weeks. Thanks for that. It only took them 10 months. Nothing to really be boasting about. Also, they mention the Member's final claim was processed....actually no. I still have 3 claims that are still in the appeal process that I have not been paid on, and one claim that HMSA has not paid on due to needing more information. Ironic on this claim, as they paid a % of the surgery, but at this point are denying the anesthesiologist claim. They are requesting proof that his services were needed. I guess you're supposed to have surgery without anesthesia?? So using the term "final payment has been made", implying that HMSA has fulfilled their requirement of paying on all my claims is not an accurate statement.
For the fourth paragraph "HMSA did not receive the claim documents until Aug 24". This is another complete lie. The first time the claims were sent to HMSA on May 25th at 9:12am to [redacted], with my assigned ref case # [redacted]. My last sentence of that email said if there were any questions to please contact me. After 2 weeks with no acknowledgement, I sent a follow up email (attached to the original email) on June 9th at 12:27pm stating, "can someone please confirm that this email was received" Again no correspondence from HMSA. I then called the customer service line and spoke with Kristine who said she saw the emails but didn't see any claims attached. I asked how come no one responded back that there were no claims attached, she requested I send them again. So I sent a 3rd email with the claims attached on June 13th at 6:28pm. I then followed up with a couple calls after that and actually on July 8th was told my claims were being reviewed and processed. I then sent a 4th email on August 8th at 2:42pm following up on the previous emails. Again, no response from anyone. I called back on Aug 15th and was told that all the claims had been "assigned" to a claims adjuster at the end of July. Again, I still wasn't seeing any payments from HMSA and called again and was finally told by a CS agent that she wanted to get my case up to higher mgmt and I was put in contact with a Claims Manager David A[redacted], who asked me once again to forward the claims, since they had no record of them - so I did so on August 22nd at 2:15am. He suggested that since the files were large they might not have come thru, but I asked why then did no one contact me to have them resent and why would the CS agents say they were received and being processed? He had no answer for that. Before telling lies, it might be prudent for HMSA to ask their IT department to pull emails from their server just to make sure that what they are going to be putting in an official document is true. Everything I have said is true, and I have the emails to prove it. Once again, as I mentioned in my first letter. I can provide copies of all email correspondence I have sent to HMSA.
For the 5th paragraph, she seems to imply that I have been unresponsive to emails /phone calls. Again incorrect. I have responded to ALL emails that the [redacted] department has sent to me. I have copies of all those emails too. I received only one voicemail on my cell phone on Oct 31st, at the time I was deployed to help out with the Hurricane relief efforts and was working out of a temporary office, with a temp phone, but I returned the phone call within the hour and spoke with the agent. I did mention that he could call me back on that number if he had further questions since at the time I was stateside, and that way he didn't have to call my German cell phone number. A couple weeks later he must have given my number to his colleague as a way to contact me, but by that time I had deployed to Puerto Rico for Hurricane work and no longer had access to that phone. So yes, it was not possible to contact me on Nov 17th at that phone, sorry that HMSA had to leave 3 voicemails. Nor did I respond to the email sent on the 17th either, as I was in a country with little electricity and spotty internet connection, sorry but there were higher priorities going on. If HMSA had paid the claims on a timely basis, and would finish paying the outstanding claims, we would not be having to have phone/email discussions 10 months later. And yes, as of their letter on 20th Nov, I hadn't responded to their email, BUT when I arrived back to Germany on the 20th, and checked my emails on the 21st, I did respond back to Ms. G[redacted]. So please don't imply that I am unresponsive, its an insult.
Truthfully, the only response HMSA should be giving me is "sorry, we and [redacted] have messed up, there's no reason this should be taking so long, and we'll fix it". I don't need the Legal Affairs Dept creating falsehoods and trying to cover themselves, acting like they are trying to cover themselves for a lawsuit. I just want HMSA to pay my claims. I pay for health insurance every month out of my federal paycheck and in return when I require healthcare services I expect my insurance company to stand up and do their job. I expected way more out of HMSA.
Sincerely,
[redacted]
We are writing in response to the September 15, 2017 complaint to your office, to which you assigned ID number [redacted]. You requested that we review the Member's concernsand respond to your office regarding those concerns by October 10, 2017. This letter is HMSA's response to the...
Member'sconcerns.HMSA apologizes for its delay in resolving this Member's issue.There are many "moving parts" that have been complicating resolution of the Member's claims. What HMSA received from the Member on
June 12, 2017 was not a claim form, but rather an itemized
invoice. HMSA sent that invoice via a claim misroute process to [redacted] of Minnesota. HMSA did so because [redacted] Clinic is a
contracted provider with that plan and
HMSA honors any contractual requirements between the provider and the local plan, such as payment direction and fee schedules. [redacted] of Minnesota informed HMSA that it could not send HMSA the information required because the invoice was missing the diagnosis codes and place of service.HMSA asked [redacted] of Minnesota to have [redacted] Clinic submit a
claim to [redacted] of Minnesota, which would Include the missing information needed to process the Member's reimbursement. Mayo Clinic informed HMSA that the Member did not provide the complete subscriber identification number.This prevented [redacted] Clinic from submitting a claim for processing. HMSA has provided [redacted] Clinic the complete identification number, and [redacted] Clinic has agreed to submit a claim to [redacted] of Minnesota.. Additionally, because the member is an HMO member, his benefits do not include coverage for services received outside of his health center unless the services are urgent or emergent, or unless his primary care physician first submits a referral for approval. HMSA is in the processo f confirming with the member's PCP that he referred the member to [redacted] Clinic for
the services at issue.Further complicating the issue is the fact that HMSA is the member's secondary coverage. The member's primary coverage is [redacted], provided through a plan by [redacted]. Therefore, his HMSA plan needs to be coordinated with his coverage with [redacted] before the member's reimbursement can be processed. The documentation the member provided HMSAdoes not containthe member's Explanation of Benefits for the receivedservices, only screenshots of claims. These screenshots only reflect no financial responsibility by the member, and does not include the total charge, description of the services,or the amount that [redacted] paid for those services. HMSA needs this information to coordinate benefits with [redacted]. We have confirmed with [redacted] Clinic that they will provide us the primary payer information with their claim so that we can coordinate benefits.An HMSA Manager spoke to the member on October 6, 2017 to explain the steps HMSA is
taking to resolve his complaint. The member expressed understanding of the steps HMSA is taking to resolve his concerns and was pleased that HMSA provided him with an update.matter.Please feel free to call me at [redacted] should you have any questions regardingthis