Highmark Blue Cross Blue Shield

This is in response to your Revdex.com inquiry ***.The claim we received for the services our member received on April 19, 2014, at MedExpress Urgent Care in *** *** 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 incurredTherefore, the previously denied claim has been reprocessed and a corrected Explanation of Benefits statement recently sent to the memberThis statement advised the member of the updated, correct patient liability of a $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

This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted aboveThe member states in her complaint that she experienced problems when utilizing the pediatric dental benefits included in her health insurance policyThe member states that she was unable to obtain services and had a pediatric dental claim deny due to this issueOur research showed that the problem was related to a system error that caused the member’s dental enrollment information to be inaccessible to our dental insurance departmentThat issue has been corrected and the member’s dental policy is showing active for The member has been reimbursed for the pediatric dental claim for the date of service December 9, 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 madeThe 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 membersOn 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 are not metIf you have additional questions, please contact me directlySincerely, *** ** Executive/Legislative Inquiries

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.Ms***, This is in response to the recent answer I received from BC/BS. I do not agree with their billing or accounting of how much I have paidI am sending you another copy of my payment history that has come out of my account to them, each payment except for a couple is an automatic paymentIf I am looking at it correctly, they are missing four $payments.Thank you,*** ***

Dear Mr***:This letter is in response to your inquiry that was received at Freedom Blue PPO onNovember 12, regarding complaint ID #***.Ms*** *** is filing a complaint against Freedom Blue PPO regarding her request toreceive the Freedom Blue PPO plan materialsMs***
states that she hascontacted the plan numerous times to request the information but has yet to receive it.I have investigated this issue and the plan materials were sent to Ms*** via overnightcarrier on November 10, I placed a call to Ms*** on November 21, Sheconfirmed that she received the requested information the previous week, and did notneed anything further regarding this issue.I apologize for any confusion this issue has causedIf Ms*** has any additionalquestions or concerns, she may contact a Freedom Blue PPO Customer ServiceRepresentative at ###-###-#### Monday through Sunday 8:a.mto 8:p.m.Sincerely,*** **CMS Complaint Specialistghrnark

Revdex.com Attn: Jennifer Gasser *** *** *** *** ***
*** ** ***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 he made his initial payment for his health care plan through the electronic bill payment service of his bankHe stated he waited three weeks before contacting Highmark Customer Service regarding the status of his account because he had not received his identification cardsHe stated he was advised the payment, was not applied to his account and that he had to supply payment information so that the payment could be located and appliedThe member stated the payment was moved to his account, but there was a delay time of approximately one week, during which time he was unable to use his insuranceThe member requests that the effective date of his plan be moved to May 1, 2015, because he was not able to use his policy the month of April.Highmark’s records indicate the initial payment for the member’s policy was received March 25, The payment did not include the billing account information and placed in an account for unidentified cashThe payment was manually moved to the correct account on April 15, 2015, after the member contacted Highmark Customer ServiceBecause the payment was not automatically applied to the member’s account, Highmark had to manually activate the plan and request the identification cardsIt takes approximately seven to fourteen business days to receive identification cards after they are requestedIdentification card requests were made April and May 4,2015.Highmark cannot change the effective date of the member’s planBecause his plan was purchased through the Federally Facilitated Marketplace, the member would need to contact them to request a change in the effective dateAlthough the member did not have his identification cards in the month of April, medical claims can be submitted to Highmark for consideration under his benefitsIf the member paid for medical services or prescriptions out of pocket, he can submit claims with receipts.On behalf of Highmark, I apologize for any anxiety or frustration experienced as a result of these mattersWe strive to provide efficient, courteous and quality serviceEven when these standards are not met, we are continually working to improve our service to meet the needs of our valued customers.If you have additional questions, please contact me directly.Sincerely,*** ** Appeals Coordinator Phone: ***

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 states in their complaint that she contacted Highmark to advise she was switching insurance companies effective January 1, 2015. The member
was advised on December 16, 2014, that she needed to contact the *** *** *** *** to cancel her coverage. Highmark did not receive a cancellation file from the ***, and per the guidance from the ***, the member was automatically enrolled for the benefit year 2015. Highmark has since received a cancellation file for the member, thus we have cancelled her policy effective January 1, 2015. The member may disregard any invoices pertaining to the policy 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 Sincerely, *** ** Executive/Legislative Inquiries Highmark Inc

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, Prior to the current group,
they
were eligible under the previous group from an effective date of April 1, 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 Please understand Coordination of
Benefit questionnaires are issued to all employees upon initial enrollment and annually unless
the employer group requests otherwiseMembers are responsible for returning the form or
contacting us to update their filesIn 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 policyHowever, if
dependents are listed on the policy there may be instance of another parent covering the
dependent on a separate policyIt 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
dependentA follow up notice was sent on August 12,2013, to which no response was
receivedOn 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 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 sameAll claims and member contacts are housed under his identification
numberPlease know our files were updated with the information advising no other insurance
was in affect for his dependentAll claims for his dependent were adjusted as of November 3,
Our files show that new questionnaires are scheduled to be sent in November
I would also like to explain that although this member states that Highmark only allows 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 statementsThe dependent’s claims were not reprocessed in
response to an appeal, but due to the required information being received as indicated in the
previous paragraphKeep 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~

This member is currently enrolled in a Preferred Provider Organization through an employergroup with an effective date of October 1, 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 visitOur records show that a single claim was submitted with two visits reported forthe same date of serviceThe 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 reportedAlthough this is not a common practice, providers may do this if theyfeel that services they provided were more than just preventive careOur files further indicatethat during the Appeal process, the Appeals Analyst contacted the physician’s office to verifyaccuracy of what had been submittedThe physician’s office indicated that although the memberwas present for a preventive visit, medical issues were also discussedProviders 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 ScheduleDuring the appeal process one additional test was determined to be eligiblefor reconsiderationHowever, the rest of the claims processed according to the terms of his PPO agreementThe 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 PreventiveScheduleAt 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-If you have additional questions, please contact medirectly.Margueritte Merkel-SullivanExecutive/Legislative Inquiries

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 belowI received the attached bill from my doctor office and it was declined for payment by Highmark. I called the doctor office today and they wanted to put me on a payment plan. I then spoke with Highmark and they said it would be reprocessed but it would take to weeks. I have a doctor today and hope this situation is solved.Regards,*** *** this is a bill for my eye examination from *** ***. Highmark insisted I use them if I wanted to be reimbursed by them. Now they are denying the charge. Can you help methis?TThank you,*** ***

This member is currently enrolled in our PPO Blue HDNP policy on an individual direct payment
basis with an effective date of April 1,
After reading this member’s complaint, I contacted the management of the Customer Service
Department to verify the event described by the memberThey
have confirmed that this member
had two instances of our pulling payments from his bank account, but were unable to do so due
to nonsufficient funds
The first instance of nonsufficient funds occurred on February 28, Unfortunately, our
billing system did not identify and/or register the transaction as nonsufficient finds, but allowed
the amount of $to register as a paymentIt was not identified until June 5, 2014; at that
time the paid to date was corrected, and the next invoice listed the amount as past due, The
Amount Due indicated on our invoices indicates the amount that will be drawn from our
members’ accounts for those who chose to pay online
The second instance of cur being unable to receive payment due to nonsufficient funds occurred
on September 2, This was due to the fact that the member owed $at that time, The
member had called into question the billing issues and was upset about the bank fees that he
incurredPlease recognize that Customer Service had offered to reimburse the bank fees;
however, they require copies of bank statements showing the fees that were assed to himHe was
provided a fax number and a mailing address to which he could forward the requested Although the member has been previously advised that his paid to date was October 1, 2014, a
review of the member’s payments was performed, and it has been determined that the
member is currently paid to August 1,However, due to the issues that have occurred with
the first nonsufficient fund transaction not registering until June, a special handle flag has been
placed on this member’s account to keep his coverage from cancelling, thus allowing him time to
make payments that will bring his account current,
A summary of his payments is being sent to him by Customer ServiceIf for any reason he
disagrees with the amount he has paid, he may forward the corresponding bank statements to be
reviewed along with the bank fee information
If the member has any questions concerning this coverage, please have ** contact our
Customer Service Department at ###-###-####If you have additional questions, please
contact me directly

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 diagnosticIn future visits, Highmark covered similar diagnostic laboratory tests under my coinsuranceHad that preventative code never been entered, Highmark would have approved this claimHighmark determined this was not a preventative care appointment, so as such, the terms of my insurance state that these tests are covered under my coinsuranceIn 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

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
policy. Based on the fact the Highmark did receive the updated enrollment file, Highmark has cancelled the member’s 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 directlyIf you have additional questions, please contact me directlySincerely, *** ** Executive/Legislative Inquiries

Revdex.comAttn: *** *** *** *** *** ***Pittsburgh, PA
15220 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 regarding his Comprehensive Care Blue PPO health plan that he has made all of the required premium payments but has no coverage. He stated he has sent in proof of payment and is unable to use his prescription coverage.The member made his initial payment via telephone on December 29, 2014. Unfortunately, when the payment was made, it applied to the billing account of a terminated policy. The payment is currently being moved to the correct billing account. A protective hold has been put on his account to prevent it from terminating while the payment is being moved. The member’s prescription coverage is active. If the member paid out of pocket for any prescriptions, prescription claim forms can be sent to the member and he can submit them with the paid receipts for reimbursement. I have provided the forms for the member’s convenience.On behalf of Highmark, I apologize for any inconvenience or frustration experienced as a result of this matter. 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 customers.If you have additional questions, please contact me directly. Sincerely, Cassandra M*** Appeals Coordinator Phone: ***Cc: *** ***

Revdex.com,Attn: *** *** *** *** *** *** *** *** ** ***Case ID: *** File Number: ***Dear *** ***: ;This is in response to your follow up inquiry sent to us on behalf of member identified by the Case ID number noted above.The member stated in is complaint that Highmark Blue Cross Blue Shield insisted that he use *** *** for an eye exam due to their level of participationHe stated the claim was denied payment.The claim in question originally denied because of the issues involving the member’s billing accountThe billing issues have been corrected and the paid to date has been updatedThis claim has been submitted for reconsideration per the benefits of the member’s planIt takes approximately three to four weeks for a claim to process and the member will receive a new Explanation of Benefits when the claim has finalized.If you have additional questions, please contact me directly.Sincerely,Cassandra M.Appeals Coordinator Phone:***

This letter is in response to your inquiry dated February 10, concerning the delaysassociated to our receipt of the necessary form from the customer and in the processing of apayment under the customer’s Health Savings Account,According to our records, the form we received is signed by the
customer and dated January 29,The customer was advised on February 6,9, and 10, of the pending requestOn February 11, a deposit in the amount of $was completedIf the customer has any additional questions or concerns about this matter, a Customer Advocateis available at ###-###-####,If the Revdex.com has any questions or need additional information, please contactme directly

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

Revdex.comAttn: *** *** *** *** *** ***
*** ** ***
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 states in their complaint that Highmark did not credit their account for the two payments that were made in 2014, that Highmark denied payment for medical services that were rendered, and that Highmark has not refunded the member for those paymentsThe member says that after writing to Highmark, requesting to cancel the coverage that Highmark sent a letter that said the member had been insured; however the member feels that the statement of coverage was fraudulent. On June 10, the member was contacted via telephone in response to their written correspondence to Highmark, and was advised that the payments made on January 14, and February 14, had applied to the health insurance coverage for the months of January and February 2014, as the policy was effective January 1, 2014. A follletter was also sent on June 11, verifying that information. The denial of services that the member is referencing is pertaining to services obtained during the month of March 2014. Because there were only two premium payments made which applied toward January and February, any claims for services after February 28, would not be eligible for payment. The denied claim was for date of service March 3, 2014, and denied appropriately.If you have additional questions, please contact me directly. Sincerely, *** *** Appeals Coordinator Phone: ***

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.The member stated in his...

complaint he did not receive his initial premium invoice which caused his initial premium to be late. He stated that his premiums are paid on time but his insurance plan was cancelled. He stated his claims have been denied and he has not received claim reimbursement forms that were requested.According to Highmark’s records, the enrollment files received from the Federally Facilitated Marketplace (FFM) had errors which prevented them from being systematically uploaded. The application was manually unloaded and the initial invoice was mailed on January 14, 2015, The initial invoice was for January and February, 2015. When the initial payment was made it was for January only. Because this was not the total amount due on the invoice the system automatically cancelled the plan.A file was systematically uploaded from the FFM with a March 1,2015,  effective date. The new file received from the FFM contained incorrect rates for the member. The incorrect rates caused billing errors which stopped the invoices from being generated and the paid to date from updating properly.The rates have been updated and the Total Responsible Amount, effective March 1, 2015, is $304.35. The billing is being corrected. Once corrected invoices will generate and the paid to date will update. This will allow claims to process according to the benefits of the plan. The current paid to date is June 1,2015. I have mailed medical and prescription reimbursement forms to the member on May 11,2015.On 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 customers.If you have additional questions, please contact me directly.Sincerely,[redacted]. Appeals Coordinator Phone: [redacted]

February 9, 2015     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.   Highmark received a passive enrollment file from the [redacted] on December 5, 2014, that reenrolled the consumer’s 2014 insurance policy for the 2015 benefit year.  On December 10, 2014, Highmark received an enrollment file in relation to the consumer choosing a new insurance policy for 2015.  Unfortunately, the [redacted] did not send a cancellation file for the consumer’s 2014 policy that was passively reenrolled by the [redacted].  This resulted in the consumer being enrolled in two policies.  This caused their billing account to be in error, which prevented their invoices from being processed and mailed to them.   Highmark has cancelled the 2014 policy and the consumer is only showing active in their [redacted] effective January 1, 2015.  ID cards were mailed to the consumer on February 4, 2015.  The consumer’s account has been put on a billing hold due to the billing error.  She may contact Highmark Customer Service to make a premium payment or wait for a corrected invoice If you have additional questions, please contact me directly.                                           ...⇄ Sincerely,                                                                                         [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 below.[redacted] please see the attachment for rejection of "[redacted]" from Highmark at the [redacted] Pharmacy.  I made all the payments on time. My 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]