Highmark Blue Cross Blue Shield

November 4, 2015Revdex.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.The member stated in her...

complaint that she enrolled in a health care plan for an effective date of February 1, 2015, and made the initial payment on February 2, 2015. She stated the payment was withdrawn from her bank account with no problems. On February 26, 2015, the member stated she received a letter from Highmark Blue Shield that stated her policy had been canceled for nonpayment of premium. She stated she contacted Highmark Customer Service and the Customer Service Advocate (CSA) stated that she would send a request for a reinstatement and contact the member back when the issue was resolved. The member stated she spoke with a CSA on March 3, 2015, and was advised that the issue was still processing. She stated she advised the CSA that she wanted to make the March premium payment, but the CSA advised that she was not able to accept a payment until the policy was reinstated. The member stated she again contacted Highmark Blue Shield on March 12, 2015, regarding the reinstatement of her plan. She stated the CSA advised her that the policy was still under review and that an answer should be received very soon. The member stated she did not receive any notification of the reinstated via phone, mail or email. She stated she again called the beginning of April and was advised by a CSA that she would receive written notification of the reinstatement resolution.The member stated she did not receive any notification of the reinstatement but did receive an invoice in the mail on May 2, 2015, with an amount due of $535.48. She stated that the invoice included February’s premium, which she paid. The member stated she wrote three letters to Highmark instead of calling because her promised callbacks were not received. She stated the only reply she received from Highmark were form letters dated September 8, and September 14, 2015, advising her of the termination of her policy. The member stated that she would simply like to get a refund on the money she paid because she feels she was unable to use the plan.According to Highmark’s records the member contacting Highmark Blue Shield on February 2, 2015, and made the initial payment for her healthcare plan. The member contacted Highmark on March 3, 2015, regarding the cancelation notice she had received and the CSA advised she would request the member be reinstated because the plan had been canceled in error.On March 12, 2015, the member contacted Highmark Blue Shield requesting the status of her reinstatement. The CSA advised her that it can take approximately thirty days for a reinstatement request to be processed. The member advised that her daughter had a doctor’s appointment and was concerned because of the status of her account. The CSA attempted to contact the member’s physician to explain the situation with the account but was unable to talk to anyone. The CSA advised the member to keep the appointment because Highmark would reprocess the claims if necessary. Highmark has no record of additional calls or letters received from the memberThe original CSA attempted to contact the member on April 28, 2015, to advise that the policy was reinstated to the original effective date of February 1, 2015. There was no answer but a voice mail was left for the member regarding the reinstatement. Highmark does not send letters when an account has been reinstated. The invoice the member received on May 2, 2015, had a total amount due prior to May 17, 2015, of $401.61. This amount was for the months of March, April and May.There is a claim on file that initially denied in March. That claim is being reprocessed according to the member’s benefits. A new Explanation of Benefits will be mailed to the member when the processing is finalized. Highmark cannot retroactively cancel a member to the original effective date without a directive from the Federally Facilitated Marketplace (FFM). If the member contacts the FFM and they advise Highmark to retroactively cancel the plan, a refund in the amount of $133.87 will be mailed to the member and the plan canceled effective February 1,2015.If you have additional questions, please contact me directly.Sincerely, Cassandra M.Appeals CoordinatorPhone: [redacted]

After talking the associate, I contacted Fisher-Titus billing center and asked them to correct the billing amount that BC/BS required. And then, I received a correct billing letter from Fisher-Titus billing center and forward to BC/BS last month. Like the BC/BS associate said, as soon as BC/BS received the correct billing letter, BC/BS will pay the bill. Yesterday, I received a letter from Fisher-Titus saying that the bill is still not paid, and will have my account placed with a collecting agency.BC/BS pays the bill as soon as possible as they promised. Fisher-Titus : [redacted] Account number: [redacted] Patient: [redacted] Amount: 432.97 ---------------------------------- Member name: [redacted] Member ID: [redacted]

Revdex.comServing Metro Washington DC and Eastern Pennsylvania[redacted]Attention: [redacted]ID Number: [redacted]Dear Ms. [redacted]:This is in response to your inquiry sent to us on behalf of the member identified in your inquiry by Case ID [redacted]...

regarding prescription drug expenses that the member incurred in September and October 2012.We have no record of the member questioning the processing of these 2012 charges until a recent contact was made to Customer Service on May 31, 2016, Because the member is questioning charges that were to have been reimbursed almost four (4) years ago, I have requested the claim information related to that time period. However, this information has been purged and will take approximately an additional seven (7) to ten (10) days to be retrieved. Once this information has been received, I will provide you with an updated response with additional information.I can, however, confirm that the prescription receipts that the member submitted indicating a payment was made to the pharmacy for $4.00, $6.00 or $8.00, was less than the amount of the prescription drug copayment that was applicable at that time under his benefit plan. In 2012, for up to a 31-day supply, the member’s benefit plan applied a $10.00 copayment for generic prescription drugs and a $30.00 copayment for brand prescription drugs, Therefore, our records indicate for the following dates of service, no reimbursement would have been due to the member because the cost paid to the pharmacy was less than the copayment that would have applied, per the member's benefits:Date indicated on prescription drug receipt Amount indicated as payment made to pharmacy9-7-2012 $4.009-7-2012 $4,009-7-2012 $4.009-7-2012 $8.009-7-2012 $8,0010-2-2012 $4.0010-3-2012 $6.00 Additionally, the prescription drug receipt dated October 3, 2012, indicating a patient payment of $30.00, was the correct brand prescription drug copayment that would have been the member’s responsibility. Therefore, no reimbursement would have been due for this charge,The member also submitted only cash register receipts for the following dates; July 12, 2012, July 19, 2012, July 29, 212, August 10, 2012, August 14, 2012, and August 21, 2012. These cash register receipts did not include a matching prescription drug receipt from the merchant’s pharmacy department, but the amounts indicated on these receipts indicate the costs associated with the member’s prescriptions were either less than the plan’s applicable copayment ($4.63 and $4.89), or the total amount of the generic drug copayment, $10.00, Therefore, there would be no additional reimbursement due for these charges. If the member has any questions concerning this information, please have them contact our Customer Service Department at [redacted]. If you have additional questions, please contact me directly.Margie L[redacted]Executive/Legislative Inquiries

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]

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.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]The amounts are all paid out of pocket which I should be refunded back. Almost 4 years of waiting and Lied to is not good business. Didn't have co-pays. Amazing how they can take someones hard earned money and put them through so much then give less and call it ok. not acceptable. almost killed me!
Regards,
[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.
The August 7th payment was made after calling Highmark to review the reasons for the double invoice amount due.  Regardless of the August 1st payment date, I needed the time to determine the issue and resolve it.  I never received any additional notice aside from the July statement and was lead to believe making the payment in August resolved the issue.  I also paid Septembers as well without issue.  A 31 day grace period on a policy that is invoiced every 30 days seems set up to intentionally fail if there is ever a mistake.  There is not an option to automatically make payments either via the online system or the mailed invoices.  Regardless if it's a "Correct" cancellation due to non-payment, it seems rigid and intentionally unfair especially considering this affect someone's health and well being.  The careless attitude of the staff, billing department and this claim is not how I'd expect a health insurance company to act.  I've purchased new insurance starting Jan 1st with another company.  I would still like my insurance reinstated retroactively - as the non-payment was unintentional and resolved as soon as I was made aware.  
Regards,
[redacted]

Dear Mr. [redacted]:This is in to response to your inquiry sent to us on behalf of the member identified by your ID of [redacted].Our records show this member’s most recent coverage was in effect from January 1, 2015 to February 1, 2015.  As the member indicates, she had made her initial payment...

via a credit card payment; however, an invoice was automatically issued with the first month's premium listed . The member sent in a second payment via a checkThe member and her spouse contacted Highmark to request to the refund of the second and although she was due a refund of in the amount of $463.53, an incorrect amount of $453.53 was issued to her. Please be assured the additional $10.00 refund was requested and mailed to the member on February 20, 2015. On behalf of Highmark, please extend my apology for any inconvenience that may have resulted from the delay.If the member has any questions concerning the $10.00 check, please have her contact our Customer Service Department at ###-###-####. If you have additional questions, please contact me directly.Sincerely, [redacted] Executive/Legislative Inquiries

March 17, 2017Revdex.comAttn: [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.The member stated in her...

complaint that in December 2016, she contacted Highmark to find out if a Magnetic Resonance Imaging (MRI) of the [redacted] would be covered. She spoke to two different Customer Service Advocates (CSA) on two different days. Both of the CSAs told her that if she went to [redacted] Hospital to have the MRI done she would not have to pay anything. On December 27, 2016, she had the MRI done at [redacted] Hospital, and afterwards she received a bill for the MRI in the amount of $3,848.90. She contacted Highmark, arid the CSA advised her that she would listen to her calls from December, and if she was told that the MRI would be covered at 100 percent, Highmark would reprocess the claim. The member stated that now every time she calls Highmark they advise that they are still waiting on the proper department to listen to the call. This has been going on for over a month now, and she is worried that her bill will soon be overdue. The member would like for Highmark to pay for the MRI that Was performed at [redacted] Hospital in the amount of $3,848.90, because she was misinformed by a Highmark CSA.Highmark thoroughly reviewed the calls made by the member to Highmark Customer Service in December 2016. On December 6,2016, the member called Highmark Customer Service and asked the CSA if a routine mammogram and MRI of the [redacted] would be covered. The CSA advised that as long as the mammogram is routine it would be covered at 100 percent and the MRI would apply towards her deductible. The CSA also advised her to get the procedure and diagnosis codes, and call back to verify it would be covered. On December 13, 2016, she called with procedure code [redacted] and diagnosis code [redacted] to verify if the MRI would be covered. The CSA advised that was a covered code and would be covered per her benefits.On December 21, 2016, the member called again to verify if there would be a copay for the MRI of her [redacted]. The CSA advised that it would be covered with no copay and she would not have to pay anything because it was fully covered. This information was not correct and staff education will be provided to the CSA who misadvised the member. Highmark has reprocessed the member’s claim for the MRI of the [redacted] showing no member responsibility. She will receive a new Explanation of Benefits (EOB) once the claim has been finalized.On behalf of Highmark, I apologize for any anxiety or inconvenience this issue may have caused the member. If you have additional questions, please contact me directly.Sincerely,Michelle D[redacted]Executive/Legislative InquiriesPhone:[redacted]

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 invoice. The invoice was generated on April 7, 2015, for the May billing period. On the day the invoice was generated, there was a past due amount of $382.96 was due on the account. Since the invoice was for the billing period of May 1 - May 31, 2015, it also included the May premium of $255.31. 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 8 and April 13, 2015, totaling $255.32 and a payment was moved from her previous billing account totaling $127.66. At that point the total due for May, 2015, was $255.29. An invoice was generated for June, 2015, on May 8, 2015, showing a total balance due of $510.60. However, a payment was received on April 28, 2015 for $127.66 but it was applied to the previous billing account. The total amount due on the account for June, 2015, is $382.94, this includes a past due balance for May of $127.63 (see chart below).   Invoice Balance / Date Previous Balance Payment Date Payment Amount Remaining Balance $638.27/April 7 (May Invoice)   April 8 $127.66 $510.61   $510.61 April 13 $127.66 $382.95   $382.95 April 9 $127.66 $255.29 $510.60/May 7 (June Invoice) 510.60 May 11 (applied to wrong acct. 4/28/15) $127.66 $382.94  The due date for premiums is always the day proceeding the first day of the month. For example, the premium for June, 2015 would be due May 31, 2015. There is a ninety-day grace period associated with the account. This 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 issue. I 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 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]

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] My complaint was resolved to my satisfaction. Highmark has agreed to cover my health bills because of an error on there part. This was all I was asking of them. Thank you [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.  I appreciate your apology for my frustration. I also made a request on 12-28-15 when I made my first payment by phone. That is probably why in the last week or two I have receive 4 benefit books. Thank you for taking care of this. I only wish it was done in the time frame I was told it would be done. I do believe it is unfair that the whole country has to do their insurance at the same time & during the holidays at that. But then if the leadership of this country doesn't care about God or the people that do & celebrate those holidays what should we expect?Again thank you.
Regards,
[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 resolution. Like I have said before I have made payments twice a month since the beginning and should NOT have anything past due. I have received one check from them for over $200 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 year. I 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 due. Thank you!Regards,
[redacted]

This letter is in response to your inquiry sent to us on June 22, 2017, on behalf of the memberidentified by Case ID [redacted].Our records indicate the member is enrolled in a Health Maintenance Organization (I-flvIO)through an employer group. This Grandfathered group is fully-insured and provides a...

three-levelappeal process.Network providers are obligated to submit claims on behalf of their patients. Out-of-networkproviders do not have an agreement with the plan to submit claims for services provided.However, many out-of-network providers will submit claims as a courtesy to their patients.As explained in the benefit booklet, in the event a provider refuses to file a claim, an itemizedbill is required along with a completed claim form to have services considered. A completedstandardized 1SOOS form should contain the necessary information. If that is not available, anacceptable itemized bill includes the following.• The name and address of the service or pharmacy provider. For a professional provider,if their National Provider Identifier (NPI) is not given, the billing should include theirprofessional status (MD, LSW, RN, etc.), and state license number• The patient’s full name• The complete date of the service, supply or purchase (month/day/year) and the locationof the service (office, hospital, home, etc.)• For professional claims, the current procedural terminology (CPT) code of the serviceprovided, or a detailed description of the service or medication/supply. The CPT listingof descriptive terms/identifying codes for reporting medical services/procedures wasdeveloped and is maintained by the American Medical Association (AMA)• The amount charged per service• For a medical service, the diagnosis/nature of illness. This can be a narrative format or codefrom the International Classification of Diseases Clinical Modification Reference (LCD-b)• For durable medical equipment, the doctor’s certification of medical necessity• For ambulance services, the total mileage, and starting/ending locations (home tohospital, hospital to skilled nursing facility, etc.)• Drug and medicine bills must show the prescription name, national drug code (NDC)number and the prescribing provider’s name.Keep in mind, cancelled checks, cash register receipts or personal itemizations are not acceptableas itemized bills. Also, if the claim was filed to another health insurance policy first, and thecurrent claim submission is for secondary benefits, it must include the explanation of benefitsstatement showing payment or denial made by the primary carrier.The previous billing statements submitted for March and April 2017, were itemized andconsidered for benefits. Those received recently for April and May were not. Billing statementsfor ongoing services must contain the required isd’ormation on each bill submitted. We areunable to utilize information from a previously submitted billing statement submitted to facilitateprocessing of a subsequent billing statement that is incomplete.The member also expressed dissatisfaction with the amount of time for claims processing. ThePrompt Payment Provision of Act 62, as mandated by the Pennsylvania State Legislatureprovides for prompt payment of clean claims within forty-five (45) days of the insurer’s receiptof the claim. A clean claim is defined as “a claim for a payment for a health care service whichhas no defect or impropriety. A defect or impropriety shall include lack of required sustainingdocumentation or a particular circumstance requiring special treatment which prevents timeLypayment from being made on the claim.” The claim received April 12, 2017, for the March andApril services was finalized within the required forty-five (45) day period on May 17, 2011.If the member has additional questions, their designated service area is most qualified to assistthem. Knowledgeable service representatives are available at the number listed on theiridentification card.Sincerely,Ms. M[redacted]Regulatory/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. 
Billing on the first 2 weeks of the month is not true. I repeatedly  get bills at the end of the 3rd week expecting them to be credited on my account by the 31.  In February  I spoke to a agent who admitted this does happen and they were told hold off of denying claims...
Regards,
Deborah Drummond

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]

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 would like contact Ms. Margie directly.  The number Blue Shield was not valid.
[redacted]
[redacted]

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 was contacted by Highmark on June 26, 2015, to see if his wife had received her benefit book. He states that when he advised she had not, that the Highmark representative advised that she would print and mail it herself by June 29, 2015. He further states that the previous response did not reference the fact that the benefit book was not mailed when his wife made her initial payment, nor was it mailed after the subsequent requests.I contacted the member on June 26, 2015, and spoke to her husband. When he advised me that his wife had only received a second member identification card, but had not received a benefit book, I apologized and advised him that I would ensure one was printed and mailed as a priority. I advised him that I could see where the initial request was made for mailing on April 16, 2015 as well as the second request on May 5, 2015. The request on May 5, 2015, was canceled in error. I worked directly with our enrollment area to ensure a benefit book was printed and mailed on June 26, 2015 and sent to the member using overnight delivery. I confirmed via the United States Postal Service website, as well as with the member’s husband via telephone on June 30, 2015, that the benefit book was received on June 27, 2015.If you have additional questions, please contact me directly.Sincerely, Linda S[redacted]Appeals CoordinatorPhone: [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 was enrolled in a health insurance policy in 2014 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, 2014 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 policy. Highmark 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 directly. Sincerely, [redacted] Executive/Legislative Inquiries

June 12, 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. In their complaint, the member is stating that he received a statement with an outstanding balance of $139.40.   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, 2015.  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] was still charging them $214.55.  I have reviewed the member’s account, and the April 21, 2015, claim in question was processed correctly.  The claim applied $100.00 to the member’s deductible, as well as the $5.00 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, 2015 and only owes the July premium payment which is reflected on the invoice generated on June 8, 2015.  There is not a statement showing that the member owes an outstanding amount of $139.40.  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]