Highmark Blue Cross Blue Shield

July 19, 2016Revdex.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 2012.We have no record of the member questioning the processing of these 2012 charges until a recent contact made to Customer Service in May 2016, Because the complaint filed to your office did not include specific dates of service or amounts related to each service, the information provided in this response refers to a claim the member submitted in October 2012, A review of this claim information confirmed that the member had not previously received reimbursement for six (6) prescription drug expenses. Therefore, [redacted] recently forwarded the member two (2) checks; check number [redacted] for $8.15 was sent on July 10,2016, and check number [redacted] for $257.19 was sent on July 16,2016. I am providing a summary of the check/payment information and the prescription dates the payments are related to:  Pate Indicated on Prescription Drug Receipt Total Rx Charges Copayment Amount Amount Paid Check Number and Check Date 9-24-2012 $18,15 $10.00 $8.15 7-10-2016 9-7-20120 $14.78 S10.00 $4.78 7-16-2016 9-21-2012 $160.62 S10.00 $150.62 7-16-2016 9-21-2012 $79,08 $10,00 $69.08 7-16-2016 9-21-2012 $34.72 S10.00 $24.72 7-16-2016 9-24-2012 $17.99 $10.00 $7.99 7-16-2016  I can confirm that the prescription receipts indicating a payment was made to the pharmacy for $4.00, $6,00, $8.00 or $30.00, was equal to, or less than the amount of the prescription drug copayment that was applicable at that time under the member’s 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, or equal to, the copayment that would have applied, per the member's benefits: Date Indicated on Prescription Drug Receipt Amount Indicated as Payment Made to Pharmacy 9-7-2012 $4.00 9-7-2012 $4.00 9-7-2012 $4.00 9-7-2012 $8.00 9-7-2012 $8.00 10-2-2012 $4.00 10-3-2012 $6.00 10-3-2012 $30.00Lastly, the member included only cash register receipts for certain dates, but did not include a matching prescription drug receipt, A review of our records indicate for the dates that the member included only cash register receipts, the amounts indicated on those receipts are for copayments that would have been the member’s responsibility. I am also providing a summary of these services for your reference: Date on Cash Register Receipt Amount Indicated on Cash Register Receipt Date Rx Filled by Pharmacy Copayment Amount 7-12-2012 $4.63 7-10-2012 $4.63 7-12-2012 $4.63 7-10-2012 $4.63 7-12-2012 $10.00 7-10-2012 $10.00 7-12-2012 $10.00 7-10-2012 $10.00 7-19-2012 $4.89 7-17-2012 $4.89 7-19-2012 $10.00 7-17-2012 510.00 7-29-2012 $10.00 7-27-2012 $10.00 7-29-2012 $10.00 7-27-2012 $10.00 8-11-2012 $10.00 8-10-2012 S 10.00 8-14-2012 $4,63 8-13-2012 S4.63 8-14-2012 $4,63 8-13-2012 $4.63 8-14-2012 SI 0.00 8-14-2012 $10.00 8-21-2012 $4.89 8-19-2012 $4.89   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,Sincerely,Margie L[redacted]Executive/Legislative Inquiries

June 24,2016Revdex.com[redacted]Attention: [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], and their recent, additional comments related to our previous responses submitted to your office.A review of our records located recent correspondence received from the member which included a provider billing statement that provided the required information to forward additional reimbursement to the member. Therefore, an additional payment has been forwarded to the member on June 23, 2016. They should receive the updated Explanation of Benefits statement and check/payment within the next seven (7) to ten (10) days.Combining the initial payment originally paid to the member, and the recent payment that has been forwarded to them, reimbursement for the total charges related to the services in question has now been made directly to the member. Therefore, forwarding payment to the out-ofnetwork provider for the services the patient received would be considered the responsibility of the patient.If the member has any questions concerning this information, please have them contact Customer Service at [redacted]. If you have additional questions, please contact me directly. Sincerely, Margie L[redacted]Executive/Legislative Inquiries

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 she had a credit balance on her Comprehensive Care Blue PPO 1500 plan when it ended on December 31, 2014, that was to be transferred...

to her Shared Cost Blue PPO 1500 plan that was effective January 1, 2015. Because the payment was supposed to be transferred she stated she paid the difference in premium amounts between the two plans for the Shared Cost Blue PPO 1500 when it began. The member stated she received an invoice in January, 2015, advising she owed over $80.00. She stated she called Highmark Customer was advised by a Customer Service Representative (CSR) that the credit from the 2014 policy had not been moved to the new account and the Shared Cost Blue PPO 1500 would cancel if the payment was not received. The member stated she made the payment that day but the policy was still cancelled. She stated it was reinstated but all medical services had to be paid out of pocket during the time it was cancelled. The member stated she spoke to a CSR in March, 2015, regarding a refund she was supposed to have received and was advised she owed an additional $40.00 on the account after she had made two payments of $127.66.According to Highmark’s records, the member contacted Highmark Customer Service on December 17,2014, and verified the Shared Cost Blue PPO 1500 plan was actiye. She also made a payment of $88.21 to pay the difference between a credit on her previous billing account and the new premium amount The CSR advised the member that the credit from the previous account would be transferred to the new billing accountOn January 1,2015, the member spoke with a CSR to confirm the receipt of the $88.21 payment and to verify the movement of the credit The CSR advised the payment was received but applied to the incorrect account. A protective hold was placed on the account so it would not cancel while the Billing Department moved the payment and the credit to the correct account.On January 21, 2015, the member contacted Highmark Customer Service requesting the status of the payment and the credit that was being moved. The CSR advised the member that $167.10 was moved to the new account and an $83.59 refund was requested. The CSR advised the member when she received the refund she could sign it over to Highmark and return the check; the member agreed.On February 10,2015, the member called Highmark Customer Service regarding the status of her billing account. She was advised by the CSR that her Shared Cost Blue PPO 1500 plan was cancelled due to Highmark error and it would be reinstated.The member’s Shared Cost Blue PPO 1500 plan is now active. All of the payments that were to be moved to the member’s current billing account have been moved. There is a credit remaining on the previous billing account which is being refunded to the member in the amount of $211.25. The member should receive the refund in approximately seven to fourteen business days. The invoice for May shows the member has a past due balance, which is incorrect, the payments have all been moved and the current amount due for the plan is $255.29. Provided that amount is paid by the due date, the invoice for June, 2015, will show $255.31 due.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,Cassandra M[redacted] Appeals Coordinator Phone[redacted]

December 20, 2016Revdex.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.In her complaint,...

the member states that she and her husband enrolled in coverage through the Federally Facilitated Marketplace (FFM) in February 2015. She states that at the time of enrollment, they were advised their son was eligible for Medicaid, and could not go onto their Highmark policy. She states that Medicaid advised them that he was not eligible, and at that time they contacted the FFM to have him added to their Highmark coverage. A couple of months after adding him onto their policy, they were notified that their son did qualify for Medicaid and they received his Medicaid card. They again contacted the FFM and had him removed from their Highmark policy.The member further states in her complaint that her husband’s birthdate was initially incorrect on the FFM enrollment file, causing Highmark to invoice them the incorrect premium for several months. She states that after several attempts to have the billing corrected, they received an invoice which stated they owed Highmark over $700 to bring the account current. Because they were advised they must pay this higher premium or lose their coverage, she states her husband was forced to go without his medications for a month. The member is asking for someone to review the account, and ensure that there are no more issues with the billing.Highmark has reviewed the member’s account. On February 26, 2015, Highmark received an enrollment file from the FFM. This file included the member and her husband only, effective March 1, 2016. This application had the incorrect birthdate for her husband. On April 3, 2016, a new enrollment file was received from the FFM. This file had the correct birthdate for her husband, which resulted in adjustments to the billing to correct the previously invoiced amounts.On August 26, 2015, another file was received from the FFM, which placed the member’s son on the policy retroactive to March 1, 2015, and cancelling his coverage effective August 6 2015. This file however, did not include his premium. He was added to the policy, but the billing was not updated. It was not until August 2016, when the September invoice was generated, that the account was adjusted to reflect their son’s premiums for the six month he was on the policy in 2015. This resulted in a significant balance to the member.Upon reviewing the account and speaking to the member, Highmark has made the determination to write off the premiums they paid for their son. Medicaid had covered him from his date of birth, and the updates sent to Highmark from the FFM were not accurate. The total paid in premiums for their son was $709.42, and a refund in that amount was issued on December 16, 2016.On behalf of Highmark, I apologize for any anxiety or frustration the member 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,Linda K[redacted]Executive/Legislative InquiriesPhone: [redacted]

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 her complaint, the member states that she did not receive an invoice for the April coverage period.  The member states she called Highmark Customer Service on April 6, 2015, and was advised that the policy would be reinstated, and that the reinstatement would take two to three weeks.  On June 1, 2015, the member received an invoice in the amount of $532.17 for the April, May, and June coverage periods.  The member further states that she called Highmark to cancel her coverage after receiving that invoice, as she felt she should not be held responsible for premium payments for the months she felt she did not have coverage.   The member wants to cancel her coverage and to have an account balance of $0.00.  After reviewing the member’s account, I have determined that the policy did in fact cancel in error during the month of March.  This cancellation was reversed and processed on May 21, 2015.  With a reinstatement, the policy would be reactivated with no lapse in the coverage, and the member would be responsible for the premiums for that time period.  Any medical services or prescriptions paid for by the member could still be submitted for processing according to the terms of the policy.  We have received a cancellation request from the Federally Facilitated Marketplace (FFM) effective June 16, 2015.  However, because the member is paid to April 1, 2015, the policy will be retroactively cancelled back to the paid to date, and the member will not owe any further premiums.  If you have additional questions, please contact me directly.                                           ...⇄ Sincerely,                                           ...⇄ [redacted].                                         ...⇄ Appeals Coordinator                                         ...⇄ Phone: [redacted]

Revdex.com:
I was contacted today by Linda S[redacted] from Highmark to see if we had received the booklet.  I informed her all we had received was another ID card.  She stated she could see on the computer that again the booklet was not mailed and that she would print it and mail it on Monday the 29th.Also their response did not cover the fact that when my wife made the 1st payment on 04/10/2015 the booklet was not mailed at that time and was not mailed after my 1st or 2nd request or after my wife requested it.  I do not know which request was cancelled by mistake or even that I believe that as an answer at this point.
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.
Regards,
[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and it still doesn't seem to be correct, but my current invoice on Highmark's website seems to be correct now, so I am dropping it strictly because I am tired of going back and forth and not really getting anywhere. The most recent letter states that my total balance due by June, 27th is $398.72. Looking on their website, my balance due is actually only $278.24, and not due until July 1st.
Regards,
[redacted]

June 15, 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. The member states in their complaint that medical claims have been denying due to an incorrect paid to date in Highmark’s system.  The member states that Highmark has acknowledged this is an error within the internal systems and that they have contacted Highmark several times to have the issue resolved, but that claims are still denying for this reason.  The error within the billing system has been identified and the member’s account has been corrected.  The member is currently paid to July 1, 2015.  Billing is being systematically updated to reflect the January through June transactions.   Once the invoice for July generates and the member’s paid to date is correctly advanced, the denied claims can be adjusted.  Once the claims finalize, the member will receive new Explanations of Benefits.  If you have additional questions, please contact me directly.                                           ...⇄ Sincerely,                                                                                         [redacted]                                         ...⇄ Appeals Coordinator                                         ...⇄ Phone: [redacted]

Jennifer, Case Id #[redacted]. The $456.00 charge for [redacted] Emergency Med Associates, paid to subscriber. Issued 12/15/15, check number [redacted], cashed 12/23/15, in  the amount of $456.00. The charge for $945.00?? for [redacted] Hospital for the date of service 06/07/15,. The...

charged amount is  $1,757.50, the allowed is $483.96, we paid $445.43, the patient responsibility is just a $50.00 copayment. Thanks, Theresa Theresa G[redacted]Member Grievance and AppealsPhone#: [redacted]Fax#: [redacted]Email: [redacted]

March 3,2016Revdex.com of Western Pennsylvania, Inc.Attn: [redacted]Member ID: [redacted]FileNumber: [redacted]Dear Ms, [redacted]:Please allow this letter to serve as a response to your inquiry sent to us on behalf of member identified by...

the Case ID number noted above.The member stated in the complaint that their plan was cancelled despite having made regular premium payments. The plan was cancelled effective November 1, 2015 for non-payment. The member notes that they have routinely sent in payments and Highmark WV continued to cash their checks for November 2015, December 2015, and January 2016. The member also notes that they did not receive notification that they were at risk to cancel.The member is enrolled in a Highmark WV Shared Cost Blue PPO $1,500 deductible plan with an effective date of January 1, 2015. The member’s monthly premium for 2015 was $1,303.13. For plan year 2016, the member’s monthly premium is $1,658,51. The member’s plan has been reinstated as of March 3, 2016. and all payments have been accounted for. However, the member is currently paid to only February 1, 2016, and thus would need to make premium payments for February and March’s coverage periods immediately to avoid cancellation. February’s premium was due on or before February 1, 2016 and March’s premium was due on or before March 1, 2016. The plan has a grace period of thirty one days. To be paid to April 1,2016, the member will need to pay a total of $3,317.02The member’s payment history is as follows:    Invoice History Payment History Coverage period Invoice Date Due Date Past due balance on invoice Payment date Payment. amount January 2015 12/30/2014 01/05/2015 No 01/06/2015* 1303.13 • February 2015 01/08/2015 01/31/2015 No 02/09/2015* 1303.13 March 2015 02/07/2015 02/28/2015 Yes 03/10/2015* 1303.13 April 2015 03/07/2015 03/31/2015 Yes 03/30/2015 1303.13 May 2015 04/08/2015 04/30/2015 No 06/08/2015* 1303.13 June 2015 05/08/2015 05/31/2015 Yes 06/08/2015 1303.13 July 2015 07/03/2015 07/20/2015 No 07/31/2015* 1303.13 August 2015 07/10/2015 08/01/2015 Yes 09/23/2015* 1303.13 September 2015 08/08/2015 09/01/2015 Yes 09/23/2015* 1303.13 October 2015 Policy termed N/A N/A 11/23/2015* 1303.13 November 2015 10/08/2015 11/01/2015 Yes 12/15/2015* 1303.13 December 2015 11/10/2015 12/01/2015 Yes 01/04/2016* 1303.13 January 2016 12/09/2015 01/01/2016 Yes 01/26/2016* 1658.51 February 2016 01/09/2016 02/01/2016 Yes N/A N/A* denotes late payment The undersigned notes that throughout plan year 2015 and into 2016, the member has consistently made payments late or after the grace period of thirty-one (31) days had passed (1). Upon cancellation, Highmark WV was prepared to refund the member’s payments made for November, December, and January in the amount of $4,264.77, however, because an Affordable Care Act (“ACA”) compliant plan is eligible for one reinstatement in a twelve month period and a maximum of two reinstatements for the lifetime of the policy, Highmark WV will reinstatement the plan for a second and final time (2). As noted above, the member has not made their February or March premium payments, which are now both past due. The member is encouraged to contact Highmark WV and arrange for payment of at least February’s payment as soon as possible to avoid cancellation.Finally, if the member has incurred any out of pocket costs above their member responsibility per the applicable Certificate of Benefits, they are encouraged to contact Highmark WV Customer Service to obtain reimbursement claim forms.Highmark WV appreciates the opportunity to research and respond to this member’s complaint and is hopeful that the matter has been resolved to the member’s satisfaction. If you have additional questions, please contact me directly.Sincerely,Courtney N, L[redacted]Associate Counsel[redacted](1)Per the member’s Certificate of Benefits booklet; "Grace Period. A grace period of thirty-one (31) days from the due date will be granted for ihe payment of each premium. During the grace period, the Agreement will stay in force; however, no benefits will be paid for services Incurred subsequent to the Agreement's then current paid date, subject to Subsection B. BENEFITS AFTER TERMINATION OF COVERAGE of this Section. If appropriate payment is not received at the end of thirty-one (31) days, this Agreement automatically terminates as of the then current paid date without written notification to the Member.”(2)Per the member’s Certificate of Benefits booklet: “Reinstatement, If this Agreement is terminated due solely to nonpayment of the premium, coverage will be reinstated if the Subscriber, within thirty-six (36) days from the end of the Grace Period, tenders and the Plan receives payment of the premium required for reinstatement The Member(s) and the Plan have the same rights under the reinstated Agreement as they had under the Agreement immediately before the due date of the defaulted premium. The right of the Subscriber to have this Agreement reinstated is limited to one (1) reinstatement during any twelve (12)-month period and to two (2) reinstatements during the Subscriber’s lifetime."

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.
Regards,
[redacted]

It appears that Dr. [redacted]'s office may have submitted both a claim for preventative care and a routine appointment simultaneously. However, the purpose of this appointment was routine, as was the lab work ordered. Dr. [redacted]'s office has told me the are resubmitting a corrected claim and are having [redacted] do the same.  I ask Highmark to process these quickly and correctly and for the Revdex.com to continue to monitor this with me until a resolution is reached. I appreciate your help. I do think Highmark has a practice of denying lab work it shouldn't that is ordered as a result of seeing a doctor during a preventative appointment--which almost makes doctors have to "see no evil" until the next appointment because they can't order lab work that isn't on the special schedule. This can cost lives, and Highmark should review this policy to find a way to avoid doctors ordering unnecessary preventative tests, but still being able to order diagnostic tests for things revealed during a preventative exam.

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]

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

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

The member identified in your inquiry is indicating that our Customer Service Departmentdisconnected his call after he indicated that his office had recorded lines and advised ourrepresentative that their call was also being recorded.Our representative was unsure how to handle the call, and he had...

to verify procedures. Duringthis time, he did place the member on hold to verify how to handle the call. After he reviewedthe applicable procedures for our Customer Service Departments, our representative did advisethe member that he was required to disconnect the call.Our procedure indicates that even if the caller indicates they have stopped recording, the callmust still be disconnected, and no calls will be accepted from the member for the rest of thebusiness day. Our representative advised the member with alternative solutions; he could callthe next day or he could submit his request in writingKeep in mind that the issue that initiated the call was a matter concerning the reinstatement ofthe policy. Our representative completed the reinstatement process after the call had ended.If the member has any questions concerning his coverage he may contact our Customer ServiceDepartment at ###-###-####. If you have additional questions, please contact me directly.Màrgueritte M[redacted]Executive/Legislative Inquiries

This member is currently enrolled in our Comp Care Blue policy, a Preferred ProviderOrganization, on an individual direct payment basis from January 1, 2014.I understand the member is dissatisfied with our timing of our invoices being delivered comparedto the due date of the requested premium....

Please recognize our invoices are issued with anexpected delivery date to fall between the second and third week of the month. The due date ofthe premium will be the last day of the month prior to the upcoming coverage period. Forexample, April’s premium will be due by March 3rdAlso, if a payment is received but not yet applied, we currently have a process in place tosuspend claims so that they do not deny for coverage if a member’s paid date is in the process ofbeing updated. After a review of this member’s claim, I was unable to find any denied claims onfile since five claims were adjusted last year between March and April of 2014.If the member has any questions concerning her coverage, please have her contact CustomerService Department at ###-###-####. If you have additional questions, please contact medirectly.

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 will not know for sure whether their response is accurate until approximately 3 weeks from now when I receive my invoice, but since I only have 10 days to respond I will accept the resolution for now until I receive my next invoice, in hope that it will truly be resolved. 
Regards,
[redacted]

Review: I have had several issues with my insurance company for months now. Quite often, I never receive bills, and can't log on to the website half the time. When I finally received a bill, they claim I was three months behind. I spoke to an agent on the phone, and my account was so messed up, she had me on hold for a long time, and then finally had to call me back. When she did, it was no help. She basically said the issue was fixed, but as I checked my balance owed later, it was not. I have tried to send a message on the website, and never received a response. I have tried and tried to reach customer service, and it's always busy. My insurance went active on the 1st of March, 2016. Since then I have paid $623.60. My premium is $139.12 per month. Even if you include June's payment, which is not yet due, that would come to $556.48. That means I have over-paid them by $67.12, and yet I still have a balance of over $400? How? I have been cut off- have been paying for prescriptions out of pocket, and in the midst of some health issues, I can't keep my appointments, or schedule the ones I need, because my doctors aren't getting paid. My most recent visit to my family doctor cost me $95 out of pocket.Desired Settlement: My account needs to be updated. I want it shown how much I've paid, and should no longer have a balance, and I want my insurance re-instated immediately. Also I would like to be reimbursed for what I've had to pay out of pocket that should have been covered by my insurance, and any claims filed need to be paid. From here on out, I would appreciate it if I could always receive my bill every month in the mail.

Business

Response:

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 she has had several issues with Highmark. The member stated that often she doesn’t receive her monthly billing statements. The member also stated that she has issues logging on to her online account. The member stated when she finally does receive her monthly billing statement; Highmark claims she is three months behind on her monthly premiums. The member stated she contacted Highmark and the Customer Service Advocate advised the member that her issues were fixed. The member stated that when she checked on balance online after the call was completed she still had a balance. The member stated her insurance became active on March 1, 2016, and she has paid a total of $623.00. She stated her premium is $139.12 per month, including June’s payment she should only owe $556.48 and have a credit of $67.12. The member stated she cannot pick up her prescriptions and has been paying out of pocket for them. The member stated she cannot keep her appointments or schedule new ones because her doctors are not getting paid. The member stated she paid out of pocket $95.00 for her last visit to her primary care provider.Highmark has reviewed the member’s billing. The member owes a total of $744.08 for 2016, and she has paid a total of $623.60. The member currently owes $120.48 to be paid to date July 1, 2016. The member’s coverage began on January 1, 2016. If the member does not feel this is the correct effective date she will need to contact the Federally Facilitated Marketplace (FFM) to file an appeal. Highmark is not authorized to make changes to eligibility dates.From January 1, 2016 to March 1, 2016, the member’s Total Premium was $372.80, with an Advanced Premium Tax Credit (APTC) of $279.00, making the Total Responsible Amount (TRA) $93.80. At this time the member received the non-tobacco rate, since her application had her listed as a nonsmoker. Highmark received a new file with effective date March 1, 2016, changing the member’s Total Premium to $382.12, with an APTC of $243.00, making the TRA $139.12. The Total Premium increased effective March 1, 2016, due to the most recent application submitted by the FFM which had her listed as a smoker. Therefore; the member is now receiving the tobacco rate.On behalf of Highmark, I apologize for any anxiety or inconvenience this issue may have caused. If you have additional questions, please contact me directly.Sincerely,Michelle D[redacted]Appeals CoordinatorPhone: [redacted]