Highmark Blue Cross Blue Shield

Revdex.com Attn: [redacted] ***Case ID: [redacted] File Number: [redacted] Dear [redacted] :This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.In his complaint, the member states that he has previously been advised by Highmark Customer Service to obtain his vaccinations at [redacted] PharmacyHe states that he went there and was only approved for his [redacted] vaccine and not for his [redacted] He further states that he has requested a list of approved pharmacies that are contracted with Highmark for vaccines and has been advised to keep trying different ones.I have reviewed the member’s account, and his claimsI have confirmed in our system that [redacted] pharmacy in [redacted] , West Virginia, and [redacted] Pharmacy in [redacted] , West Virginia, are both contracted as In Network pharmacies to administer the [redacted] vaccineI contacted both of these locations and confirmed with the pharmacists that they do in fact submit electronic claims to Highmark for vaccinesOur records indicate that the claims on file for the [redacted] vaccine were submitted by [redacted] Pharmacy on June 3, 2015, and [redacted] Pharmacy on June 5, Neither of these pharmacies have contracts with Highmark for administration of vaccinesTo date, Highmark has not received a claim from [redacted] PharmacyThe member may go to either of these [redacted] pharmacies and have the vaccine administered, and they will submit the claim to Highmark.Unfortunately, Highmark does not have a printed listing of pharmacies contracted to administer vaccinesPharmacy participation can change, therefore we recommend that our members call to confirm that the pharmacy they plan to visit is contracted to submit claims for administering the vaccinesBecause pharmacy participation for vaccines is a recent change, it is possible that at the time he received his [redacted] vaccine last year that [redacted] was not contracted for vaccines other than the [redacted] vaccine.If you have additional questions, please contact me directly.S [redacted] Appeals Coordinator Phone: [redacted]

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[redacted] please see the attachment for rejection of " [redacted] ***" from Highmark at the [redacted] Pharmacy I made all the payments on timeMy PCP still says I have an outstanding balance due to Highmark rejecting my insurance coverage I'm sorry, I haven't been on the Revdex.com site and hope the case is still open.Call with any questions ) work ( [redacted] ) or (home [redacted] )Thanks for all your help [redacted]

The response did not address the concerns for the claim that to date has still not been handled; only spoke about enrollment which had been settled prior to making the complaint Regards, [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 Regards, [redacted]

June 17, 2015Revdex.com Attn: [redacted] ***Case ID: [redacted] File Number: 15161512628Dear Ms [redacted] :This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated in her complaint that she did not agree with the amount that has been posted on her billing account for the policy that became effective January 1, She stated that based on the previous payment history received from Highmark, four payments are missing.After reviewing the proof of payment submitted by the member with her complaint, four payments were located, and are currently being applied to the correct billing accountThree of the payments were applied to the member’s previous billing account, which is no longer active, and the fourth payment was in an unapplied cash accountAdditionally, the member returned the refund of $211.25, and it is currently being posted to the active billing accountWhen all payments have been moved to the proper account, the member will have a credit balance of $211.29, and a paid to date of July 1, 2015.When members make payments whether through their banks bill payment system or send a check to Highmark, it is very important that their current billing account number be on the paymentIf the incorrect account number is placed on the payment, that payment may not be posted to the correct account, and the member could possibly be cancelled for nonpayment.If you have additional questions, please contact me directly.Sincerely,Cassandra M.Appeals Coordinator Phone: [redacted]

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 was previously told by a Highmark Customers Service Agcent to get my shots at [redacted] Pharmacy which I did and was approved only for my [redacted] shot and not the shingles shot I keep requesting a list of approved Pharmacies that Highmark has contacted with and I am told to just keep trying different ones Regards, [redacted]

This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted aboveThe member was enrolled in a health insurance policy in that did not meet the requirements of the Affordable Care Act (ACA) because it did not provide coverage for the Essential Health Benefits (EHB) required by the ACA The member was notified that they would be transitioned into an ACA compliant policy effective January 1, 2015, unless they contacted Highmark or the Federally Facilitated Marketplace to choose a different plan The member contacted Highmark on December 31, to change their plan Due to the volume of applications received at that time, the member’s applications experienced a delay in processing This resulted in the member receiving invoices for the policy that she had been transitioned from and for their new policyHighmark has verified the member is paid to date and in good standing On behalf of Highmark, I apologize for any inconvenience that the consumer may have experienced due to this matter If you have additional questions, please contact me directlySincerely, [redacted] Executive/Legislative Inquiries

February 23, [redacted] This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member states in his complaint that he contacted the Federally Facilitated Marketplace (FFM) to change his policy for Highmark did receive an enrollment file to enroll the member into a new policy for 2015, however Highmark did not receive a cancellation file for the member’s policy Based on the fact the Highmark did receive the updated enrollment file, Highmark has cancelled the member’s policy effective January 1, On behalf of Highmark, I apologize for any inconvenience or concerns the member may have experienced due to this matter If you have additional questions, please contact me directly.If you have additional questions, please contact me directlySincerely, [redacted] Executive/Legislative Inquiries Highmark Inc.----------------------------------------------------------------------------...⇄ March 11, 2015This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member states in her complaint that she experienced problems when utilizing the pediatric dental benefits included in her health insurance policy The member states that she was unable to obtain services and had a pediatric dental claim deny due to this issue Our research showed that the problem was related to a billing error that prevented the member’s billing account showing the correct paid to date That issue has been corrected and the member’s paid to date is now reflecting the correct date All claims that were affected by this issue have been reprocessed per the member’s benefits, including the pediatric dental claim for the date of service December 9, 2014.The member states in her complaint that she was promised a return call from the Customer Service supervisor that was researching the issue for the member, and that this return call was not made The supervisor did not make the return call as promised, but noted in her inquiry the call was not made because the member had been advised of the resolution to the issue by a Customer Service representative on January 30, The supervisor has been coached on the importance of following up on promised calls to members On behalf of Highmark, I apologize for any inconvenience or concerns the member may have experienced Please be assured we strive to provide efficient, courteous and quality service and are concerned when these standards are not metIf you have additional questions, please contact me directlySincerely, [redacted] Executive/Legislative Inquiries

Revdex.com Attn: [redacted] ***Case ID: [redacted] File Number: [redacted] Dear Ms [redacted] :This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.According to the follow up complaint, the member was concerned with the resolution and wanted clarification.The Billing Department corrected the billing by creating a new invoiceThe invoice was generated on April 7, 2015, for the May billing periodOn the day the invoice was generated, there was a past due amount of $was due on the accountSince the invoice was for the billing period of May - May 31, 2015, it also included the May premium of $This made the total amount due on the account $638.27, as of April 7, 2015.After the invoice was generated, two payments were received on the account, April and April 13, 2015, totaling $and a payment was moved from her previous billing account totaling $At that point the total due for May, 2015, was $An invoice was generated for June, 2015, on May 8, 2015, showing a total balance due of $However, a payment was received on April 28, for $but it was applied to the previous billing accountThe total amount due on the account for June, 2015, is $382.94, this includes a past due balance for May of $(see chart below) Invoice Balance / Date Previous Balance Payment Date Payment Amount Remaining Balance $638.27/April (May Invoice) April $$ $April $$ $April $$$510.60/May (June Invoice) May (applied to wrong acct4/28/15) $$ The due date for premiums is always the day proceeding the first day of the monthFor example, the premium for June, would be due May 31, There is a ninety-day grace period associated with the accountThis is non-revolving grace period, which means once a member enters the grace period they have ninety days to pay the total amount due on the account to avoid cancellation.On behalf of Highmark, I apologize for any confusion or frustration associate with this issueI hope I have explained the billing process and the member’s billing account to their satisfaction.If you have additional questions, please contact me directly.Sincerely,Cassandra MAppeals Coordinator Phone: [redacted]

Dear [redacted] ***: This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted aboveThe member's spouse states in her complaint that she contacted a Highmark customer service supervisor and the [redacted] (***) and was advised that her husband's plan and her son's plan would cancel December 31, for both membersThe member’s spouse did contact Highmark on December and a conference call was done with all three parties, the member’s spouse, Highmark and the ***The [redacted] representative advised that the plans for would end December 31, with no additional enrollment information on file for Highmark did not receive a termination file from the ***, and per the guidelines from the ***, the member was automatically enrolled into the same plan for the benefit yearThose plans have subsequently been cancelled effective January 1, 2015, when the member contacted Highmark Customer Service and advised they did not want to be enrolled for The member may disregard any invoices pertaining to the policyOn behalf of Highmark, I apologize for any inconvenience or concerns the member may have experienced due to this matterIf you have any additional questions, please contact me directlySincerely, [redacted] Executive Legislative Inquiries Highmark Inc

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

June 12, Revdex.com Attn: [redacted] ** *** Case ID: [redacted] File Number: [redacted] Dear [redacted] : This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted aboveIn their complaint, the member is stating that he received a statement with an outstanding balance of $ The member also states that he called Highmark Customer Service and spoke to a Customer Service Advocate (CSA) regarding a medical claim from April 21, The member states that the CSA advised that the claim had to be refiled He further states that he went to [redacted] to receive a [redacted] and that although his benefits cover the [redacted] , [redacted] was still charging them $ I have reviewed the member’s account, and the April 21, 2015, claim in question was processed correctly The claim applied $to the member’s deductible, as well as the $office visit copay This is correct according to the benefits of his plan I have reviewed the recent premium invoices that have been sent, and they are correct The member is paid current to July 1, and only owes the July premium payment which is reflected on the invoice generated on June 8, There is not a statement showing that the member owes an outstanding amount of $ This may be a statement from his provider showing an unpaid balance, but we would not have access to any statement the provider might have sent him When the member called Highmark Customer Service on June 2, 2015, he was advised at that time that [redacted] is not contracted with Highmark to administer the vaccines A document submitted with the complaint reflects that [redacted] quoted the member the full amount on June 3, 2015, because [redacted] is not a contracted pharmacy with Highmark and is ineligible to administer it If he utilizes a pharmacy that is not contracted with Highmark to administer the vaccine, the member would be responsible for paying the full amount up front, and submitting a claim form subject to the Out of Network benefits of the policy If you have additional questions, please contact me directly Sincerely, Linda S [redacted] Appeals Coordinator Phone: [redacted]

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 Ms [redacted] ,This is in response to the rejection that I sent for BC/BS resolutionLike I have said before I have made payments twice a month since the beginning and should NOT have anything past dueI have received one check from them for over $that I have not cashed that I need to know whether or not I need to cash and send another payment into them since they couldn't seem to transfer that money into my current account like I asked several times.I would also like to have a complete break down of payments from the whole year not just a fraction of the yearI want them to look at any past requests for refunds that might be pending since one of the customer service reps alerted me to the fact that that is where some of my account money was at at one time; supposedly they take the money out of your account when there is a request for refund and it just sits there.Again I have paid twice a month since the beginning and should not have anything over dueThank you!Regards, [redacted] ***

May 29, Revdex.com Attn: [redacted] ** *** Case ID: [redacted] File Number: [redacted] Dear [redacted] : This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted aboveThe member stated in the complaint that they went to fill a prescription and received a rejection The member states that all premium payments have been made on time, and also states that their PCP says there is still a balance due because of denied medical claims This complaint is a follow up to the complaint that was filed on March 19, which was due to errors in the billing which resulted in claim denials I have reviewed the account thoroughly, and have verified that all of the issues have been resolvedThe issues within the account actually finalized on May 8, when the prescription system updated with the correct paid to date informationAll medical claims and prescription claims submitted have also been reviewed, and all have processed and paid according to the terms of the contractThe last medical claims finalized on May 7, The member should be receiving updated Explanations of Benefits for these claimsOn behalf of Highmark, I apologize for any anxiety or frustration experienced as a result of these matters We strive to provide efficient, courteous and quality service Even when these standards are not met, we are continually working to improve our service to meet the needs of our valued customersIf you have additional questions, please contact me directly Sincerely, Linda S [redacted] Appeals Coordinator Phone: [redacted]

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 Billing on the first weeks of the month is not trueI repeatedly get bills at the end of the 3rd week expecting them to be credited on my account by the In February I spoke to a agent who admitted this does happen and they were told hold off of denying claims Regards, Deborah Drummond

March 12, 2015Revdex.comAttn: David BakerHoliday Drive, Suite 220Pittsburgh, PA Case ID: [redacted] File Number: [redacted] Dear Mr [redacted] This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.This member stated in her complaint she enrolled in a health care plan with the Federally Facilitated Marketplace (FFM) in December She said that she has had numerous problems since she enrolled, including the inability to receive identification cards and invoices, problems with her billing account, and a misplaced payment She stated she has called in repeatedly to address these issuesThe member also stated that she has a difficult time reaching Highmark’s Customer Service Department due to long hold times.The member made her initial payment on December 29, 2014, but due to a data entry error the payment did not apply to her account Unfortunately, the Social Security Number was entered incorrectly and the payment went into an account for unapplied cash Because the payment was not immediately applied to the member’s account, the plan was not able to be activated and since it was not activated the identification cards were not generated Subsequently, the misapplied payment caused the account to be cancelled (the binding or initial payment was not applied by the due date) The member called in January 29, 2015, to verify her payment for January The Customer Service Representative (CSR) told the member that her initial payment was not on her account The member called back in later that same day and paid the premium for February and she was advised by the CSR that her initial payment was being moved to her account.On February 26, 2015, the member called Highmark Customer Service and questioned why she could not make payments through the member portal website The CSR advised the member her account had been cancelled due to the missing payment At that time, the CSR requested a reinstatement of the account due to the account being cancelled because of Highmark error.Re: Case ID: [redacted] Page 2On March 3, 2015, the member called Highmark Customer Service questioning the status of her account The CSR advised the member they were in the process of having the account reinstated due to issue with the initial (binding) payment The member’s policy is currently active, the payment was applied to the member’s account on March 2, 2015, and the paid to date is April 1, Our records show she has been sent identification cards and her invoices are being mailed Additionally her prescription drug coverage is active She was also concerned about the long hold times she has experienced when trying to contact Highmark Customer Service Highmark realized that prompt service is important to our customers and while we experienced longer than hold times due to the Open Enrollment Period, measures have been taken to provide the prompt, courteous service our customers deserve Customer Service lines are open Monday through Friday 8am until 8pmOn behalf of Highmark, I do apologize for the inconvenience the member may have experienced in the enrollment process If you have additional questions, please contact me directlySincerely, [redacted] Executive/Legislative Inquiries

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 belowI just received another statement showing an outstanding amount of $ I spoke with Harold at BCBS on 6/02/regarding my office visit dated of 04/21/(Procedure Code ***) He said BCBS had to re file the claimThis is to show you that I continue to have on going problems [redacted] , attached is the paper work from [redacted] showing Highmark BCBS not covering my [redacted] ! Highmark say's I'm cover for the vaccination but they won't pay any of it and you can see were [redacted] is charging me $ Can you help me resolve this matter? Thank you, [redacted] Regards, [redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Regards,
*** *** *** by the time I read this response, I had already rec'd my *** *** thru the *** *** *** ** *** *** *** ***. They will bill Highmark but I still think they'll deny the charge. I believe Highmark is continuing to play games so they don't take responsablity for their charges

May 6,2015Revdex.com Attn: *** *** *** *** *** *** ***
*** ** ***Case ID: *** File Number: ***Dear *** ***:This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated in
his complaint that he purchased his health insurance policy through the Federally Facilitated Marketplace (FFM) and added his children to his policy April 1, He stated that since he added his children, the billing has been incorrect, and that it has caused medical and prescription claims to denyThe member stated his daughter’s orthodontic claims were denied after authorization was granted from Highmark.Highmark’s records indicate the enrollment file received from the FFM contained incorrect information regarding the premium amount which caused billing errorsThis issue has been corrected and it will show on theJuly, 2015, invoice which was released May 5, The member has a total balance due of $1552.70, because the invoice is for two monthsThe member owes $for June and Sfor JulyThe system will now update normally because the billing issues have been corrected.I have contacted the dental carrier for the member’s daughter and the denied claims are being reprocessed in accordance with the benefits..On behalf of Highmark, I apologize for any inconvenience or concerns the member may have experiencedPlease be assured we strive to provide efficient, courteous and quality service and are concerned when these standards arc not met.If you have additional questions, please contact me directly.Sincerely,*** ** Appeals Coordinator Phone:***

Revdex.com of Western Pennsylvania, Inc, Attn: *** ***
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*** ** *** Member ID: *** File Number: *** Dear *** ***: Please allow this letter to serve as a response to your inquiry sent to us on behalf of member
identified by the Case ID number noted aboveThe member stated in his Complaint that Highmark WV refuses to pay every claim submitted by his treating doctor or hospital without the member first having to file an appealWhile he does note that some of the claims have since been paid, he contends that there are still outstanding claims which he believes Highmark WV should have paidThe member is enrolled in a *** *** *** *** *** *** policyThis group maintains its own benefits booklet and Highmark WV is merely the entity that administers the policy pursuant to said benefits bookletThe member may obtain a copy of his benefits booklet directly from his employerHighmark WV has not refused payment on any of the member’s claimsEach of the member’s claims, including claims for preventive health services, that were received by Highmark WV on behalf of the member have been processed and paid according to the member’s benefitsDepending on the service provided, the member’s benefits applicable to preventive health services are pay as follows: Per our records, the member has filed three (3) appeals regarding various servicesFor each of these appeals, an appropriately qualified Appeals Analyst reviewed the file including the member’s submitted appeal and determined that for specified reasons the claims were either applied to the member’s deductible and/or the coinsurance amounts the member is responsible for or they were not covered based on how the providers coded the servicesThe member was mailed detailed response letters outlining the reasons for the denials of his appealsThe member was also advised that Highmark WV cannot change or alter coding to satisfy individual payment and was also instructed to contact his provider if he felt that the claims were coded incorrectlyThe letters also advised the member that he could file an appeal with his employerWhile the member has authorized Highmark WV to release such information, due to the sensitive nature of the member’s medical information, Highmark WV prefers to defer to the member to provide copies of the referenced appeals decision letters should he choose to do soFollowing receipt of the appeals letters, the member requested information used in the review processOur records show that this information was mailed to the member on March 25, 2015.The member further noted that they received generic letters with the words “denied” stenciled in Highmark WV does not issue “form letters” with respect to member and provider appealsThe letters received by the member contained the word “denied” in bold type, which although may have appeared to be stenciled in, they were not. Finally, with respect to the member’s assertion that he has had to make direct payment to his providers, Highmark WV is without information to support this assertionIf the member has incurred out of pocket costs for any services from providers that Highmark WV subsequently paid then the member should contact his provider to seek a refund for an overpayment.On behalf of Highmark, I apologize for any inconvenience or frustration experienced. If you have additional questions, please contact me directly. Sincerely, *** ** ***
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