Highmark Blue Cross Blue Shield

Review: Highmark Blue Cross Blue Shield is my health insurance provider through the [redacted]. Highmark denied coverage for several in-network laboratory tests performed by [redacted] Labs, Inc. As a a result, [redacted] Labs now claims that I owe them $600.00 to cover the cost of these test which should have been covered under my insurance. On September 4, 2015, I made an appointment with the office of [redacted], MD in Nashville. This was my first visit with Dr. [redacted] (and my first visit to a doctor in a couple of years) and as such he provided both preventative care and requested assessment and treatment of various issues I reported during the visit. As a result, Dr. [redacted] ordered several laboratory tests, including some as preventative and some as diagnostic. All test were done after consultation with him and with his medical advice. After the appointment, however, Highmark denied my claim filed by Dr. [redacted] office to cover the appointment as a "preventative care appointment." In response, my doctor's office resubmitted the claim as a regular visit, and that claim was approved. Thus, Highmark admits the appointment was not exclusively for preventative care. Nonetheless, Highmark initially only approved some of the laboratory tests which were listed on the preventative care schedule, denying coverage for the additional tests ordered by my doctor for diagnostic purposes because they were not "preventative." On appeal, Highmark approved coverage for one additional test, but persisted in denying the remaining tests. On subsequent appeal to my employer's benefits network, that company again declined to overturn the denial claiming that only lab work ordered for preventative purposes would be covered. [redacted] Labs has worked with me to delay collections, but is not willing to do so any longer, which could result in negative credit reporting.Desired Settlement: I request Highmark again review this claim and reverse its decision to deny these laboratory tests. If Highmark disagrees and chooses to persist in its wrongful denial, I request my right for an external appeal to be completed.

Business

Response:

This member is currently enrolled in a Preferred Provider Organization through an employergroup with an effective date of October 1, 2013. This self-insured, non-grandfathered group hastwo levels of appeal; the first is administered by Highmark with an external review available formedical necessity denials only, and the second by the employer group.Under the terms of Highmark’s contract with a self-insured group, we must administer health insurance benefits in strict accordance within the terms of their benefit program.According to the member’s statement, he feels that his physician’s office submitted a claim for aroutine service which was denied, and therefore, his physician’s office resubmitted the charge asa medical visit. Our records show that a single claim was submitted with two visits reported forthe same date of service. The first charge submitted was for a preventive visit with a routinediagnosis code, and the second charge was for an office visit with medical diagnoses reported.Both charges were received on the initial submission; the claim was not reprocessed to changethe type of visit reported. Although this is not a common practice, providers may do this if theyfeel that services they provided were more than just preventive care. Our files further indicatethat during the Appeal process, the Appeals Analyst contacted the physician’s office to verifyaccuracy of what had been submitted. The physician’s office indicated that although the memberwas present for a preventive visit, medical issues were also discussed. Providers are required tobill for the services provided; they should not bill for coverage purposes only.Insofar as the laboratory service, only certain tests are considered eligible under the HighmarkPreventive Schedule. During the appeal process one additional test was determined to be eligiblefor reconsideration. However, the rest of the claims processed according to the terms of his PPO agreement. The member’s provider submitted a routine diagnosis code with procedure codeswhich are classified as medical diagnostic tests, and are not part of her group’s 2014 PreventiveSchedule. At this time, the member has no further appeals available.If the member has any questions concerning his coverage, please have him contact CustomerService Department at 1-800-648-4078. If you have additional questions, please contact medirectly.Margueritte Merkel-SullivanExecutive/Legislative Inquiries

Consumer

Response:

Highmark has failed to acknowledge that this was paid as a diagnostic appointment AND NOT as a preventative appointment, and these tests were ordered as diagnostic. In future visits, Highmark covered similar diagnostic laboratory tests under my coinsurance. Had that preventative code never been entered, Highmark would have approved this claim. Highmark determined this was not a preventative care appointment, so as such, the terms of my insurance state that these tests are covered under my coinsurance. In addition, the terms of my insurance do not dictate external reviews for medical necessity only, If further review is denied, I will report Highmark to federal authorities.

Review: July 2014 I purchased insurance from highmark thru the marketplace and had to cancel before I even used it which it was to become effective 8/1/2014,so I did cancel before aug 1 and they said I will receive a complete refund. Well wks went by and of course no refund. So I call and I was told the check was sent to the wrong address and they will void that one and send another to the correct address. Then I called many many more times and told the same thing over and over. Today 01/10/2015,5 months later,I receive a letter,dated 12/08/2014,and unsealed,that at this time they would not be able to void and reissue my refund. I cancelled the policy before it even became effective and it only took them a day to withdrawal my paymet but they will not give me my money back and I have been waiting 5 months just to hear thisDesired Settlement: My full payment which was 218.55 and would like it deposited back into my bank account,just like they received it,not by mail with the possibility of going to wrong address again or getting lost in the mail

Business

Response:

This is in response to your inquiry sent to us on behalf of member identified by the Case IDnumber noted above.The customer states that they made the first premium payment and after the policy was cancelled requested thepayment be refunded.Unfortunately, the application received from the PPM contained the incorrect address for theconsumer. A reftuid of the consumer’s premium wits mailed to the member and returned toHighmark as undeliverable, A new refund check has been reissued to the consumer at the addressprovided in the complaint. The refund was issued on January 21, 2015.On behalf of Highmark, I apologize for any inconvenience or anxiety the consumer experiencedin relation to this matter.If you have additional questions, please contact me directly.Sincerely,[redacted]

Highmark does great with their regular billing and working with hospitals and doctors. I had no problems with that. My issues were with their webpage and their processing. It took 2 months to be able to start using our account we already made payments into because their system was having trouble processing our start payment. Then when the new year started they enrolled our new plan into autopayment without my permission. I had specifically gone into our account to turn it off so that it wouldn't hit our credit card. Then when they said they would refund us, processing has taken over 3 weeks which was the time limit they had given us.

Review: I have been paying my premiums to date and in full since January 1,2015.However I keep getting notices from my doctors and other medical facilities that my insurance is cancelled for not paying! I have called customer service to resolve this issue and they say "it's all fixed" and then proceed to get prescriptions,call my hospital billing information to inform them so it does not ruin my credit only to find it is not fixed! Not only is this very frustrating but also very embarassing! On July 3,2015 I attempted to get my [redacted] refilled for my [redacted] and I was denied,now, do to holiday I can't get my medication,wrong on my part for waiting but two days prior ,I was told everything was fixed, so I will go without my [redacted] for the next three days .Because of someone not doing their job and correcting this I will pay with my health,my hospital bills piling up,I hope it doesn't ruin my credit!Desired Settlement: I want This problem resolved ASAP,I payed for this service and I expect it to be there when I need it. I want it to be corrected and not just told it's fine! This is very upsetting to me not only in not being able to get my medication but having humiliation in public when being told we have not paid so therefore we can't help you!

Business

Response:

July 17,2015Revdex.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.The member stated in his complaint that he has been paying his premiums each month since January 1, 2015, and has received notices from medical providers that his claims are not being processed due to nonpayment of premiums. The member stated he has called to have the issue resolved but there has been no resolution to date and he needs his [redacted] medication.Upon review of the member’s account, a billing error was discovered when the March 2015 invoice was generated. A new enrollment file was systematically updated by the Federally Facilitated Marketplace (FFM) on March 18, 2015. The changes in this file were effective April 1, 2015, which affected the billing system and caused additional billing issues. These billing issues were preventing invoices from being mailed to the member. Because the invoices were not generating correctly, the paid to date was not updating automatically each month as it does when the cycle runs correctly; this, in turn was causing the denial of the member’s medical and prescription claims.The member’s billing issues are currently being reviewed and a corrected invoice will be mailed to the member for the September billing period when the corrections are completed. The member is showing a past due amount for July 2015.Highmark has manually updated the paid to date and the medical claims have been reprocessed. The member can expect new Explanations of Benefits in approximately two to three weeks. The member’s prescription coverage has also been updated and he can have the pharmacy process his claims.If you have additional questions, please contact me directly.Sincerely,Cassandra M.Appeals Coordinator Phone:[redacted]

Review: Wife and I have health insurance through Highmark BCBS. My premium is paid automatically with a bank ACH. Highmark receives my payment but consistently does not credit my account. My invoices will show me being up to 3 months behind. Once they canceled my insurance for non-payment. This creates huge problems when we go to use our insurance at medical offices. The customer service people keep putting the problem on me.Desired Settlement: Don't want this to happen again and some apology for the problems and for them to admit that the problem is on their end.

Business

Response:

June 24, 2015 [redacted] Revdex.com [redacted] Re: ID# [redacted] Dear [redacted]: We are in receipt of the Complaint dated June 8, 2015 regarding the member’s ongoing billing and collection issues. The member had previously contacted the President of Highmark Inc. directly on May 25, 2015. The member’s account was reviewed with respect to the noted issues with payments not being posted to his account and revealed that the automatic payment feature with the member’s banking institution was set up with the incorrect billing account number which caused the payments to be directed to the wrong account. On Friday, May 29, 2015, the member’s payments were located and applied to the correct account. The member’s paid to date was then advanced to July 1, 2015. The member was contacted on May 29th and advised of the status of his complaint and the correction made to his account. By this point the new invoices for June had already been generated and mailed, which will account for why the June invoice remained incorrect. Highmark set up monthly monitoring on the member’s account to ensure that payments are posted correctly. Upon further review on June 12, 2015, the member’s account is still accurate and his most recent invoice was also correct. Highmark will continue to monitor this account. Highmark WV understands the frustration the member has experienced trying to get the matter resolved. We appreciate the opportunity to advocate education with our billing team to understand why there continued to be an issue and what we could do to correct it so that other members would not experience the same issues. If we can be of further assistance, please contact me at the below email address. Sincerely, Courtney N. L[redacted], Associate Counsel [redacted]

Review: I was notified on Dec 18th 2015 that my health insurance was cancelled beck on Oct 1st 2015. I was not told that is was cancelled in Oct. I was still getting medical testing done and I am still currently doing so. As I am to have surgery tomorrow Dec 22nd 2015. I was still receiving a EOB from Highmark Blue Shield and I was still paying then each month for the testing I had done. They never sent me anything saying it was cancelled until two months later, they are now refusing to pay what they said they would and have back dated it to Oct 1st 2015. I am left will a total outstanding bill of 6,282.00 for procedures I had done in Oct Nov and Dec. I would have done what ever they needed me to do if they had just contacted me to let me know that it was going to be cancelled. They also continued to cash my monthly payment knowing they had cancelled my policy. They can not cancel a policy without telling the consumer right away and continue taking there money and agreeing to pay for services received. Then they sold me a new policy starting Jan 1st 2016. That I have already paid my premium for. This has cost me so much mental distress that I cant handle right now with my health issues and being so young I am only 28 and have two small children who I am trying to be there for, for as long as I can this has really taken a toll on me.Desired Settlement: All I am asking for is the chance to make this right. I want them to pay what they said they would in the EOB (explanation of benefits) dating back to Oct 1st 2015 through Dec 31st 2015. I will pay my portion to the hospital as I would have. I am asking that they give me what I paid for already.

Business

Response:

Revdex.comAttn: [redacted]Case ID: [redacted]File Number: [redacted]Dear [redacted]:This is in response to your inquiry sent to us on behalf of the member identified by the Case ID number noted above.The member stated in her complaint that she received notification on December 18, 2015, advising that her health insurance policy was terminated effective October 1, 2015. She stated she did not receive any other notification regarding the termination of her plan. The member stated she has continued to make payments and has also made a payment on her plan that is effective January 1, 2016. The member stated she received medical care and has several outstanding bills due to the termination of her health insurance.According to Highmark’s records, the member entered delinquency July 1, 2015, because the premium payment for July was not received until August 6, 2015. Because the member has an Advanced Premium Tax Credit, there is a 90 day non-revolving grace period. When she entered the grace period on July 1, 2015, she had 90 days (or until October 1, 2015) to pay the total due on the account. Because the total amount due was not received by October 1, 2015, the policy was terminated.Delinquency letters were mailed to the member on June 15, August 28, September 23, and November 19, 2015. However, due to a systems error, the last delinquency letter was generated when the member had already been canceled. Because of the inconsistency with the delinquency letters, Highmark has reinstated the member.No payment was received in July 2015. The payment the member made for her new policy that is effective January 1, 2015, has been applied to her current plan. Because the premium amount is higher for 2016 than 2015, the member has a $93.99 credit that will be moved to her new billing account. She has a balance due of $352.45, due by January 1, 2016.Any claims that denied because of the termination of the member’s plan will be reprocessed according to her benefits. The member can expect to receive updated Explanations of Benefits in approximately four to five weeks.If you have additional questions, please contact me directly.Sincerely,Cassandra M. Appeals CoordinatorPhone:[redacted]

Review: I was seen at MEDExpress in [redacted] on April 19, 2014 about 10 days before my insurance expired through my husband's place of employment. I received a bill from MEDexpress stating that I owe 260.00 and nothing was covered by my insurance. My husband called multiple times to get no answer from anybody as to why I was not covered or phones were down. Medexpress informed me that the insurance company said I needed to fill out a Coordination of Benefits, which I never received because it was never sent to me. This is documented in another Revdex.com claim I had with Medexpress directly from the insurance company. Medexpress re-filed my claim. I see on my bill that the insurance company sent payment in, then took it back. I look at my bill from my insurance company showing what they paid, took back and that they claim I have other insurance that should have paid for this claim. I WAS NOT COVERED BY ANYBODY ELSE. MY JOB AT THE TIME DID NOT PROVIDE AN INSURANCE OPTION FOR ME. I sent a letter to Blue Cross and never received a response. This is absolutely ridiculous!!! I would like to know what other insurance I supposedly had and where it was coming from???? I was not paying into any type of insurance because I did not have the option to.Desired Settlement: I want my bill taken care of the way it should be.

Business

Response:

This is in response to your Revdex.com inquiry [redacted].The claim we received for the services our member received on April 19, 2014, at MedExpress Urgent Care in [redacted] was originally denied because our records indicated the patient had primary insurance with another carrier.Our records have been updated to indicate the patient did not have any other insurance at the time these services were incurred. Therefore, the previously denied claim has been reprocessed and a corrected Explanation of Benefits statement recently sent to the member. This statement advised the member of the updated, correct patient liability of a $20.00 copayment due to the provider.If our member has any questions concerning their coverage, please have them contact our Customer Service Department at ###-###-####. If you have additional questions, please contact me directly.Executive/Legislative Inquiries

Consumer

Response:

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

Review: health insurance will not let my wife get her prescription, she is out of pills and needs them badly.Desired Settlement: I want my wife prescription filled now........

Business

Response:

January 21, 2016Revdex.comAttn: [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 his wife’s health insurer is not allowing her to pick up her prescription. He states that she is out of medication, and needs the prescription badly. He states that his wife has been on this medication for several years and wants the prescription filled now. Upon review of the member’s account, the Highmark policy ended effective January 1, 2016. Highmark contacted the member via telephone on January 8, 2016, and the member stated she enrolled in coverage through [redacted] Health plan for the 2016 benefit period. Member was advised that if she is having difficulty filling her prescription at this time, they will need to contact the new health insurer. The member and her husband explained that they had filed the complaint due to the difficulty in filling her medication during the month of December. The medication that the member was prescribed, required a prior authorization. She attempted to fill the medication on December 22, 2015, at which time she was advised the physician would need to submit a request for authorization. The request was received on December 23, 2015. On December 28, 2015, a call was placed to the physician to obtain additional information pertaining to the request. Once this was received, the authorization was approved on December 30, 2015. The member received her medication, delivered via FedEx on December 31, 2015. If you have additional questions, please contact me directly. Sincerely, Linda S[redacted]. Executive/Legislative Inquiries Phone: [redacted]

Review: Highmark BCBS online payment system does not properly process my monthly payment, if the payment is being submitted even 1 day late, and there is no confirmation to show whether a payment was processed or not. I submitted payments in June and July and everything appeared to submit properly on the screens, but I realized days/weeks later the money was never removed from my bank account. The online system does not provide a confirmation showing that the payment was successfully submitted and the payment history online only updates online information, it does not reflect the payments that were made with agents via telephone (which had to be done since the online payment was never processed). Today, 7/14/14 I was told by customer service that the problem was not even addressed when I reported it in June. I have never used an online payment system that did not provide a confirmation screen. This is extremely poor "user friendliness" of their system, and unacceptable business practice.Desired Settlement: 1. I would like to see their online payment system produce a confirmation page showing proof that payment has been properly been received and will be processed. 2. If a payment is not able to be processed online (ex. if payments can not be accepted online a day late), then let the customer know that directly on the screen. 3. Update payment history screen to show ALL payment history, both phone payments and online payments.

Business

Response:

Case ID: [redacted]

Review: I contacted blue Cross on March 14 regarding an [redacted] billing problem. I told them that I am responsible for a 400.00 hospital stay and not a 75.00 ER visit. The agents agreed with me. I called several times to correct it and their automated system is denying the adjusted claim.Desired Settlement: A correct billing adjustment so I can collect my extra 75.00 from [redacted]

Business

Response:

March 24, 2016Member: [redacted]Group Number: [redacted]Revdex.com of Western Pennsylvania[redacted]Dear Ms. [redacted]:This letter is in response to your inquiry that was received at Security Blue HMO on March 24, 2016 regarding complaint ID #[redacted].The member is filing a complaint regarding the assessment of copays for an Emergency Room visit and an Inpatient Hospital Stay for the same dates of service.In review of the member's account, it was found that for dates of service January 9, 2016 -January 11, 2016 there are two separate claims with assessed copays. There is a claim for an Emergency Room Visit with a $75.00 patient responsibility, and a claim for an Inpatien Hospital Stay with a $400.00 patient responsibility.Per the member's benefits as outlined in the plan's Evidence of Coverage (EOC):“If you are admitted to the hospital within 3-days for the same condition, you pay $0 for the emergency room visit. The emergency room copayment applies if you are in the hospital for up to 48 hours for observation or rapid treatment as these are not considered hospital admissions.”The claim for the Emergency Room Visit has been adjusted to reflect a $0.00 patient responsibility. A corrected Explanation of Benefits statement (EOB) will be issued to both the member and the provider.I apologize for any inconvenience this issue has caused. If Mr. [redacted] has any additional questions or concerns, he may contact a Security Blue HMO Customer Service Representative at [redacted] Monday through Sunday 8:00 a.m. to 8:00 p.m.SincerelyJennifer BCMS Complaint Specialist

Consumer

Response:

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

Review: I've signed up for a new plan in November (Benefit Plan: Silver - Health Savings Blue PPO 2750 a) and I asked for my old plan to be cancelled (Benefit Plan: Gold - Shared Cost Blue PPO 1200 a). However, when billing payments have come in, they have started chaging me for both plans.

I have called repeatedly since December they either say it is a market place issue, that I am no longer covered by my old plan and it is just a processing issue that will go away in a week, or that they see I am signed up for both plans and they can't help me and they transfer me over into another department (just being sent back and forth from department to department until I get sent to a dead line).

I have been making payments for the plan I have signed up for (Benefit Plan: Silver - Health Savings Blue PPO 2750 a) and am currently up-to-date with it and recently been charged with a second month for the plan I've canceled (Benefit Plan: Gold - Shared Cost Blue PPO 1200 a).Desired Settlement: Stop charging me for the Benefit Plan: Gold - Shared Cost Blue PPO 1200 a! I didn't want it to be renewed, I've asked for it to be canceled since the 2014 calendar year, and have enrolled/been paying for a different plan...

Business

Response:

The member states in his complaint that he contacted the Federally Facilitated Marketplace (FFM) to change his policy for 2015. 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 2014 policy. Based on the fact the Highmark did receive the updated enrollment file, Highmark has cancelled the member’s 2014 policy effective January 1, 2015. 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 directly. Sincerely, [redacted] Executive/Legislative Inquiries

Review: I contacted customer service and spoke with Connie she never buys me that my sons insurance how to turn he stated that I needed to send in the premium which I stated to her that I would send it within a week since I hadn't to September 18th in order to send a premium she was very rude and last on the phone when I was stating something he interrupted me several times she then began to get me very angry upset which I did get smart with her and raise my voice which is unacceptable I file complaint in regards to another employee of hers who was hung up the phone on me when I actually supervisor she didn't call me back and stated that that was unacceptable but today over the phone and she stated that I am very rude just as her employees state to her which is very unprofessional to even state that I asked her when my sons and [redacted] was going to be retroactive because I did not know that until the end of our call I asked her supervisor she transferred me back to the operator I cannot speak to anyone because no one was availableDesired Settlement: I need to know exactly when my sons insurance would be retroactive due to the fact as I stated to her took him to the emergency room and I did not know that his policy has term because she did not advise me of that

Business

Response:

September 15, 2015Revdex.com[redacted]

[redacted]Attention: [redacted]Case ID:[redacted]Dear [redacted]:This is in response to your inquiry sent to us on behalf of the member identified by case ID [redacted].Our records show this member is enrolled on a Chip Gatekeeper policy effective September 1, 2015. Due to the enrollee’s mother’s dissatisfaction dealing with our Customer Advocates, she requested a callback from a Supervisor.A Supervisor returned the mother’s phone call on September 9, 2015, and the situation was resolved. The Supervisor had the account reactivated, and is sending a bill for September and October 2015, premiums, along with a benefit book.The mother is in the process of submitting the September 2015, insurance premium. Once the premium is received, the paid to date on the account will be updated to September 30, 2015, and the denied claim will be adjusted.The Supervisor apologized to the mother for all of the problems experienced dealing with Customer Service. At that time, she assured the Supervisor that all of her issues were resolved and she was satisfied with the outcome.On behalf of Highmark, please extend my sincere apology to the enrollee’s mother for any problems she experienced regarding the enrollment of her dependent.If the enrollee’s mother has any questions, she can contact our Customer Service at [redacted]. If you have additional questions, please contact me directly.Sincerely,Janice M[redacted]Executive/Legislative Inquiries

Review: On Dec 1st my husband went on [redacted]. Highmark and the [redacted] was contacted and his policy with them was cancelled. My son's policy was cancelled on Dec 31 by [redacted] and Highmark. I recieved notice of payment was due in January. I contacted Highmark, sat on the phone with both the Supervisor at Highmark and the [redacted] to make sure all work was done and they assured me both policies were cancelled. Several weeks later I get a billing notice (both policies), I call Highmark immediately, this time a male CS Rep said they re-enrolled us and don't know why. He checked over things, said everything was fine and that both policies were cancelled and to disregard the invoiced. Today (2.19.2015) I received again invoice notices. I called, asked for a supervisor, but the CS Rep said I need to speak to a supervisor at the [redacted]. She went on to tell me that in the notes it was suppose to be cancelled, then in another part of the conversation stated my husband and son's policies were still opened. I had enough. This company is trying to get money out of me and my family and we don't even want to deal with HIGHMARK!Desired Settlement: I loathe Highmark and their high priced barely there medical insurance. Adjust the bill, cancel it, zero it out.....PLEASE do what you were suppose to do back in January! We have been using different policies and I don't want Highmark to take the balances of both my son's and husband's policy and put it into collections for something we haven't had since DECEMBER 31, 2014! I also want a phone call from someone who actually can deal with situation, and if it is from corporate so be it.

Business

Response:

Dear [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's spouse states in her complaint that she contacted a Highmark customer service supervisor and the [redacted] ([redacted]) and was advised that her husband's plan and her son's plan would cancel December 31, 2014 for both members. The member’s spouse did contact Highmark on December 17 2014 and a conference call was done with all three parties, the member’s spouse, Highmark and the [redacted]. The [redacted] representative advised that the plans for 2014 would end December 31, 2014 with no additional enrollment information on file for 2015. Highmark did not receive a termination file from the [redacted], and per the guidelines from the [redacted], the member was automatically enrolled into the same plan for the 2015 benefit year. Those 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 2015. The member may disregard any invoices pertaining to the 2015 policy. On behalf of Highmark, I apologize for any inconvenience or concerns the member may have experienced due to this matter. If you have any additional questions, please contact me directly. Sincerely, [redacted] Executive Legislative Inquiries Highmark Inc.

Consumer

Response:

[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]

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

Review: My husband took my son to ER on 08/05/2013. After co-pay 75.00, Highmark Blue Cross Blue Shield should pay the rest. Highmark Blue Cross Blue Shield told my doctor that they sent me the check, so I should pay for the rest. I asked Highmark Blue Cross Blue Shield who and where they sent the check to, and receive no answer.Desired Settlement: My Highmark Blue Cross Blue Shield group [redacted]

Please pay 551.00 to [redacted]

or send the 551.00 check to [redacted]

Thanks.

Business

Response:

October 20, 2015Revdex.com[redacted]Attn: [redacted]Case ID: [redacted]Dear [redacted]This is in response to your inquiry sent to us on behalf of the member identified in your inquiry by Case ID [redacted].Our records indicate the claim in question was processed issuing a check to the member on January 24, 2014. Please recognize that a copy of the check was recently sent to the member on October 9, 2015, along with additional instructions pertaining to the balance on the claim.If the member has any questions concerning this coverage, please have the member contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly.Sincerely,Margueritte M[redacted]Executive/Legislative Inquiries

Review: I purchased my health insurance through healthcare.gov over a year ago. I wanted to add my children to my policy which occurred in April of 2014. Ever since then I have had billing issues. The online billing was and is not correct or up to date. and I was receiving inaccurate bills. I called approx once a month to have this issue resolved to no avail. Then in Sept of 2014 both my children needed ongoing medical attention for the remainder of the year and on into 2015. Every month at the beginning of the month my policy was being denied, I would call Highmark and they would fix it that month, but then the same issue would repeat itself. I finally escalated the issue in Jan 2015 they claimed to have fixed the issue, but it could take a few weeks to process. I have made several call to customer service and they said it could take time to fix. This issue has been going on for over a year and the issue is still present. Most recently a prescription has been denied and we needed to pay out of pocket and will need to submit a request for reimbursement. Normally I would not mind. But I am out of the country for three weeks while my mother takes care of my children. So this money came out of her pocket until I can get home to reimburse her. Not only that but Highmark is not open to call 24/7 to resolve issues like this. Not only are there billing issues, but they are denying my children orthodontics coverage after they already sent a form to the Orthodontist claiming the procedures would be covered. Desired Settlement: I want them to fix all my billing issues and any other billing issues company wide so what is displayed online matches what I owe . I want them to stop denying my chidren's orthodontics coverage. I am considering a formal lawsuit against Highmark.

Business

Response:

May 6,2015Revdex.com Attn: [redacted]

[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.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, 2014. He stated that since he added his children, the billing has been incorrect, and that it has caused medical and prescription claims to deny. The 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 errors. This issue has been corrected and it will show on the. July, 2015, invoice which was released May 5, 2015. The member has a total balance due of $1552.70, because the invoice is for two months. The member owes $776.23 for June and S776.47 for July. The 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 experienced. Please 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,[redacted] Appeals Coordinator Phone:[redacted]

Review: For 6 months, Highmark Blue Cross/Blue Shield has been saying my health insurance is cancelled because of non payment. This stops my prescription drug coverage & prevents me from having my blood pressure meds filled. They're playing with my life. June 22 I got a letter stating my insurance was cancelled back to March 1. I called Highmark & after 45 minutes & 3 transfers, I was finally told the cancellation was their error & my coverage would be reinstated but I needed to call the marketplace and get them to make necessary corrections to my plan. I called on June 24 and was told everything was in order with my application & there's no problem on their part. I called Highmark back and was told by a supervisor the problem would be rectified but it would take 2 weeks to get my insurance reinstated. My question is why would it take 2 weeks if it was Highmarks mistake. Meanwhile I can't get my medication which is necessary to prevent a heart attack or stroke.Desired Settlement: I want Highmark to clear up their mistake, reinstate my coverage and stop canceling my coverage every month.

Business

Response:

July 6, 2015Revdex.com Attn: [redacted]

[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.The member stated in her complaint that she received a letter from Highmark BCBS on June 22, 2015, that stated her insurance was cancelled on March 1, 2015. She stated she contacted Highmark Customer Service and was advised the plan was cancelled in error and that her coverage would be reinstated. She stated that she was advised by Highmark Customer Service that she would need to contact the Federally Facilitated Marketplace (FFM) to have necessary changes made to her plan. The member also stated that her prescription claims were denied because her policy was cancelled.Highmark’s records indicate that the enrollment file that was systematically uploaded for the member from the FFM had the Total Premium Amount listed as a non-tobacco user but the tobacco indicator was listed as a tobacco user. Because of this discrepancy, the billing system billed the member as a tobacco user, which has a higher premium. The member paid the amount that she was advised when she enrolled in the plan, which was the non-tobacco premium, and not what was listed as the amount due on the invoice. Because she was showing a past due balance each month, and did not pay it, she became delinquent. When she became delinquent, she had 90 days to pay the account current or it would cancel for non-payment. Since the total amount due on the account, according to Highmark’s internal billing department, was not received by the last day of the grace period, the policy cancelled for non-payment. Once her policy was cancelled, all of the claims (medical and prescription) would have denied due to nonpayment.The member’s plan was reinstated but the tobacco inconsistency was not updated because Highmark did not receive an updated enrollment file from the FFM. On June 25, 2015, I contacted the FFM with the member. A Health Insurance Casework System (HICS) Case was created that enabled Highmark to change the tobacco indicator to the non-tobacco status. Once the HICS case was received, we were able to correlate the tobacco indicator with the tobacco premium.The member’s billing account has been updated, and she should receive a corrected invoice for the August 2015 billing period which will be generated on or around July 10,2015. The amount due for July is $321.98. If the July premium is not received on the account before the invoice for August is generated, the invoice will include July’s premium amount.

Review: I submitted a member submitted health insurance form for reimbursement for services from an out-of-network provider on 1/02/2014. I followed all member submitted procedures, including using the correct form as provided by Blue Cross Blue Shield. Despite this, Blue Cross Blue Shield sent the reimbursement to my provider in early March (two months after the original claim was submitted) for $1,477.80. When I spoke with my local Blue Cross Blue Shield and Highmark Blue Cross Blue Shield no one offered to resolve this. I was made to feel this was my fault even though I followed all of their procedures. On 3/18/2014, I initiated the claims refund which Blue Cross Blue Shield of Tennessee received on 3/19/2014. It is now two weeks later and almost three months after the original claim and I have not received my reimbursement or any communication from Blue Cross Blue Shield regarding my reimbursement of $1,477.80.Unfortunately, I wish this were an isolated incident with BC/BS, but it is not. I have always had issues with poor service and untimely reimbursementsDesired Settlement: I would like my reimbursement of $1,477.80 mailed to me by the end of this week (04/04/2014). I would like better customer care and more timely resolution in the future, but I am doubtful about this given Blue Cross Blue Shield's terrible track record.

Business

Response:

Review: Applied for insurance after receiving notice that my insurance was cancelled. Gave representative $170.00 for application submission. Received letter in 3 weeks stating that my application was denied because of glith in system, and that my old insurance was reinstated. Letter stated that within 2 weeks I would be receiving my $170.00 back. This was June, 18 2013. After 4 phone calls, and only 1 call back, I have yet to receive my refund. We are now going on 2 months since this has past. I am getting extremely upset that this issue hasn't been resolved. If I were to owe HIGHMARK money, for sure they would be calling me up daily asking where there funds are at.Desired Settlement: I would very much like to have my $170.00 refunded back to me ASAP.

This company has the worst customer service I've ever experienced. We have made several calls to customer service trying rectify a billing issue they admit is their fault and still have not gotten it resolved.

Review: Blue cross blue shield has denied most of my claims from 01/01/14 until present stating that they have not been notified of me having only 1 insurance carrier. Blue cross blue shield is stating I have 2 insurances ([redacted] and [redacted]), but clearly shows that [redacted] ended 12/31/13, while [redacted] started on 01/01/14. The company [redacted] became [redacted] on 01/01/14 and should not of been an issue. I believe blue cross blue shield created this problem with everyone that worked for [redacted] and the company changed names to [redacted] in order to deny as many claims as possible. Blue cross blue shield claims that I was suppose to prove that I only had one insurance provider and that I failed to do so. When I did finally realize why the claims were denied by blue cross blue shield, I had to go to their website and select I only had 1 insurance provider, which I did in July. I also left messages, website and phone, and never received any phone calls back or messages on their website. They also claim you only have 180 days after denial to file a written appeal, which is just another attempt to deny as many claims as possible after creating this problem. They only except calls from Monday through Friday 8:00am - 5:00 pm, making it increasingly difficult for most people to resolve issues without 24 hour phone coverage. You can't even leave a message after hours. You have no choice, but try and resolve any issues on their website, which is very difficult also. I leave messages on their website and don't get any responses. Their conduct and code of ethics really needs to be investigated across the board, this is just unacceptable and just wonder how many others are involved with this issue with Blue Cross Blue ShieldDesired Settlement: I would like the claims to be honored as they should have and not being denied because they didn't have an answer of if I had more than 1 insurance carrier. This was an obvious problem created by Blue Cross Blue Shield in a new attempt to get as many denied claims as possible to anyone that did not update their status on the highmarksbcbc website to whether or not they had more than one insurance provider. Even after I updated their website accordingly, they're still denied and no one contacts

Business

Response:

This is in response to your inquiry sent to us on behalf of the member identified by your ID of

The member and his dependent are currently enrolled in a Preferred Provider Organization

through an employer group with an effective date of January 1, 2014. Prior to the current group,

they were eligible under the previous group from an effective date of April 1, 2013 until January

1,2014,

I understand this member believes his issue is a result of his company’s name change effective

January 1,2014; however, his issue began in July 2013 Please understand Coordination of

Benefit questionnaires are issued to all employees upon initial enrollment and annually unless

the employer group requests otherwise. Members are responsible for returning the form or

contacting us to update their files. In this particular member’s files, it should be noted that no

claims for the member have denied for other insurance information; only claims for his

dependent.

As an active employee, the contract holder’s policy is their primary policy. However, if

dependents are listed on the policy there may be instance of another parent covering the

dependent on a separate policy. It is in this type of situation that we need verification regarding

availability of any other insurance.

Our records indicate a questionnaire was sent on July 26, 2013, after receipt of a claim for his

dependent. A follow up notice was sent on August 12,2013, to which no response was

received. On August 23, 2013, the claim was denied, and an Explanation of Benefits Statement

for the claim was issued that indicated that payment for the claim and all future claims would be

denied until the information was received.

I understand the member is advising that he attempted to contact us in July; however, our records

show that we only received information pertaining to his dependent in September 2014. In fact,

we show no record of member contact under this member’s contract prior to September 12,

2014, and while the employer group’s name may have changed, this member’s identification

number remained the same. All claims and member contacts are housed under his identification

number. Please know our files were updated with the information advising no other insurance

was in affect for his dependent. All claims for his dependent were adjusted as of November 3,

2014 Our files show that new questionnaires are scheduled to be sent in November 2015.

I would also like to explain that although this member states that Highmark only allows 180 days

to file a written appeal for denied claims, and he feels this is an attempt to deny claims,

I-lighmark is required to provide appeal rights on our Explanation of Benefits Statements for any

adverse determinations Appeal rights, along with the reason of the denial of his dependent’s

claims, were presented on our statements. The dependent’s claims were not reprocessed in

response to an appeal, but due to the required information being received as indicated in the

previous paragraph. Keep in mind, if this member had actually filed an appeal for any of the

denied services, he would have been instructed that once he responded to the questionnaire

andlor provided the necessary information, our files would be update and the claim would be

reprocessed

Insofar as the member advising that although he contacts our Customer Service online, he does

not receive any responses, please know that online contacts are generally responded to in the

same format as they are received, I have forwarded this member’s comments to management of

our online Customer Service Department to alert them to the fact that during this member’s

recent online contact, he did request a telephone call, but our records show an online response

was sent.

If the member has any questions concerning this coverage, we do encourage the please have

contact our Customer Service Department at ###-###-####. If you have additional questions,

please contact me directly~