Highmark Blue Cross Blue Shield

Review: My wife, has had cervical facet joint injections at a local pain clinic a number of times. The injections have made it possible for her to turn her head far enough to allow her to drive, and have greatly reduced the pain in turning her head. Highmark/BCBS has paid the claims in the past. About six months ago we got a bill from Dec. 2012 for these injections from the clinic, and we were told that Highmark/BCBS no longer covers the service, but consider it not medically necessary. We cannot cover the cost, and as much as it limits us, we ask for no service that is not covered. This complaint does not involve a health issue. We are only concerned about a service which was covered and is no longer, one we would not have opted for had we known they had changed their policy. The pain clinic filed an appeal which was rejected. I filed an appeal and received no reply.Desired Settlement: Highmark/BCBS pay for that one set of injections- $1818.50 to; [redacted]

Business

Response:

ID: [redacted]

Review: I have been trying for 8 weeks to get info on how to use this insurance properly. I have had 3 people tell me & one tell my wife an info packet would be mailed to us. Eight weeks & four calls later we still have no information. The people we talked to were very nice but nothing is getting done. We have spent several hours trying to accomplish this simple act.Desired Settlement: Simply send us the info we should have received & was told we would receive 8 weeks ago.

Business

Response:

March 3, 2016Attn: [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 his complaint, the member states that he has attempted for eight weeks to receive a benefit book for his 2016 health insurance policy. He states he has called Highmark Customer Service four times and has not received the benefit book. He would like to receive the benefit book for his policy so that he can understand how his benefits work.Upon review of the member's account, there are inquiries documenting a Welcome Packet being requested on January 22, 2016, and February 22 and 25, 2016. According to Highmark's records, these requests were completed by the automated mail system. A Welcome Packet was manually printed and mailed to the member via Certified Mail on March 3, 2016.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,Linda S[redacted]Executive/Legislative InquiriesPhone:[redacted]

Review: Member #: HSN102220660001

In 11/2013, Highmark Blue Shield (HBS) notified me that they made an error and require reimbursement of payment to me for medical spending of $35. Follow up conversations with HBS confirmed that they could resolve internally without my action since there are significant claims in excess of the $35. No further correspondence.

On 1/7/2014, HBS sent me a letter that I am in collections for $35, I immediately sent $35 check and called. HBS told me that they would send me a $35 check upon receipt of my $35 due to their internal error.

On 3/10/2014, I called HBS to inquire on the $35 check to me and after apologies HBS told me that HBS will immediately process my $35 payment. On 3/12/2014 HBS called and confirmed that payment has been processed and check will be mailed. No check was received.

On 6/30/2014, after confirming on the website that the $35 has not be distributed to me, I called HBS and they confirmed that $35 is still in my medical spending account, but she could do nothing due to the timeframe. Although [redacted] confirms the entire history, HBS now says it is my fault for not filing a claim even though there are significantly more claims pending but in excess of the limit of the medical spending. I have requested a supervisor to contact me.Desired Settlement: I want the $35 check that HBS owes me.

I would like the inefficient process of HBS to be streamlined and an apology letter of their inability to resolve a basic issue.

Business

Response:

ID Number: [redacted]

Review: I purchased Highmark Flex Blue PPO 1000 insurance through the Marketplace in December 2014. Ever since that time, I have had NOTHING but problems. Highmark has cashed over $900.00 in checks from me, but continues to deny me coverage.

On January 5, 15, and 29th, 2015, I called Highmark. I waited an average time of 39 minutes each call, just to request my insurance cards. I never received them. Because I also never received a bill, I attempted to call numerous times per month in January and February, to try and pay my bill. Each time, I waited over 49 minutes per call. Because I am a full-time, single, working mother, I had to hang up sometimes, because I was at work. I finally reached a rep in January, who told me I didn't have insurance. Even though my check was cashed in the first week of January! I offered the customer service rep PROOF of my payment. At that time, she quickly realized that the original customer service rep had been using the incorrect social security number. Therefore my payment was in "limbo," and didn't belong to any name. Once I was able to provide proof of payment, she assured me that she would match the payment with the correct account. I told her I still hadn't received cards or an invoice. She assured me that they were on their way. I never received anything.

Last week, I called HIghmark Monday, Tuesday, Wednesday and Thursday. All I wanted to do was pay my bill for March. I would have loved to do this online, but according to their website, "The information you have provided does not match the information we have." After waiting over an hour each time, I had to hang up to return to work. On Tuesday, I was reprimanded at work for excessive phone time. On Thursday morning, I waited 43 minutes to speak to someone. When she got on the phone, we spoke for 4 minutes. I was then disconnected. I called back and waited 23 minutes. When the rep came on the phone, I cried, and told her I was a single mother and just desperately wanted to pay my bill. She apologized, took my payment, and promised me that we could set up an automatic pay, so that I wouldn't have to call Highmark every month and wait on hold. I checked my bank, and Highmark had no problem taking over 200.00 out of my account for March's payment.

Imagine my horror, when today, after working a 12 hour day, I receive a letter from Highmark, dated February 20, telling me that "Our records indicate that we have not received the first premium payment for your health coverage. We are sorry to inform you that as a result, your application for enrollment has been cancelled, due to nonpayment of the required premium." Please remember: I HAVE PAID HEALTH INSURANCE FOR JANUARY, FEBRUARY, AND NOW MARCH. And I have no health insurance.

I called Highmark tonight. I was on hold for one hour and 15 minutes. I'm not sure if they are open at night. Nobody would know because there is no message that indicates their records. The amount of time and energy and money that I have invested in Highmark in the last three months is astounding. Only to be told that I have no health insurance.Desired Settlement: I expect and deserve a letter of apology, and a letter PROVING that I do, in fact, have health insurance. Where are my payments going??? There is no reason a hard-working single mother deserves to be put through what I have been through with Highmark. I guarantee you that next year I will be choosing another plan.

For reference, my ID is [redacted]

Business

Response:

March 12, 2015Revdex.comAttn: David Baker400 Holiday Drive, Suite 220Pittsburgh, PA 15220 Case ID: [redacted] File Number: [redacted] Dear Mr. [redacted]This is in response to your inquiry sent to us on behalf of member identified by the Case ID number noted above.This member stated in her complaint she enrolled in a health care plan with the Federally Facilitated Marketplace (FFM) in December 2014. She said that she has had numerous problems since she enrolled, including the inability to receive identification cards and invoices, problems with her billing account, and a misplaced payment. She stated she has called in repeatedly to address these issues. The member also stated that she has a difficult time reaching Highmark’s Customer Service Department due to long hold times.The member made her initial payment on December 29, 2014, but due to a data entry error the payment did not apply to her account. Unfortunately, the Social Security Number was entered incorrectly and the payment went into an account for unapplied cash. Because the payment was not immediately applied to the member’s account, the plan was not able to be activated and since it was not activated the identification cards were not generated. Subsequently, the misapplied payment caused the account to be cancelled (the binding or initial payment was not applied by the due date). The member called in January 29, 2015, to verify her payment for January. The Customer Service Representative (CSR) told the member that her initial payment was not on her account. The member called back in later that same day and paid the premium for February and she was advised by the CSR that her initial payment was being moved to her account.On February 26, 2015, the member called Highmark Customer Service and questioned why she could not make payments through the member portal website. The CSR advised the member her account had been cancelled due to the missing payment. At that time, the CSR requested a reinstatement of the account due to the account being cancelled because of Highmark error.Re: Case ID: [redacted]Page 2On March 3, 2015, the member called Highmark Customer Service questioning the status of her account. The CSR advised the member they were in the process of having the account reinstated due to issue with the initial (binding) payment. The member’s policy is currently active, the payment was applied to the member’s account on March 2, 2015, and the paid to date is April 1, 2015. Our records show she has been sent identification cards and her invoices are being mailed. Additionally her prescription drug coverage is active. She was also concerned about the long hold times she has experienced when trying to contact Highmark Customer Service. Highmark realized that prompt service is important to our customers and while we experienced longer than normal hold times due to the Open Enrollment Period, measures have been taken to provide the prompt, courteous service our customers deserve. Customer Service lines are open Monday through Friday 8am until 8pm. On behalf of Highmark, I do apologize for the inconvenience the member may have experienced in the enrollment process. If you have additional questions, please contact me directly. Sincerely, [redacted] Executive/Legislative Inquiries

Review: I had called the office on Tuesday or Monday because I noticed the payment had not cleared yet for my son premium [redacted] (minor) I was advised that someone will give me a call back. I called back today because I rec'd a letter in the mail that if the payment is not rec'd by 12/31/15 the policy would be canceled. I spoke w/ Steven call references [redacted] and he advised me I need to call someone else ask to speak w/Stephanie who is the manager he advised me she is unavailable ask to send a email to have her call me. He calls me back and states that she is unavailable ask him unviable as she is out of the office or not able to assist me. I ask if I could leave a message he stated he had to see . I was on hold for 25min and had to hang up to get back to work. I am always having trouble with them and customer services is absolute horrible.Desired Settlement: I need to know if they rec'd my check b/c it has not cleared if not I will send another one but wont get there by 12/31/15

Business

Response:

December 31,2015Revdex.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 show a call was place by the member’s mother, (herein referred to as the member) on December 16, 2015. Our advocate advised she would have the dedicated advocate assigned to this member return her callThe dedicate advocate was not in the office con December 16, 2015, but attempted to call the member back on December 17, 2015. The advocate left a message that she would try to call her again on Monday, Dec 21 , 2015. During the call between the member and the advocate, it was determined that the member’s check had not cleared her bank, and she was concerned about sending another payment. She wanted the advocated to investigate where the missing payment was, but the member was advised we were unable to investigate the missing check since it had not cleared her bank. She was advised of the Walk-In Center in her area should she decide to make the payment.Please note that the member’s account was place on a hold so it would not terminate. The member is currently paid to December 1,2015; however, once she makes a payment in the amount of $209.00, the account will be paid to March 1, 2016.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: At the end of June I made a payment with my credit card, received a confirmation number for the July policy.

Highmark said they never received the payment and threatened to cancel coverage because they didn't receive the

payment. After repeated phone calls to them and 2 hours on the phone to them, they refused to acknowledge the payment was made. MasterCard faxed them a copy of the transaction and they refused to acknowledge that the payment was made. I have no idea on how to get this resolved. Highmark threatens to cancel the policy although they have received the payment.Desired Settlement: That highmark will acknowledge credit card payment statement

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 member identified by the Case ID number noted above.In his complaint, the member states that he had made a premium payment in the amount of $302.45 at the end of June, for the July coverage period. He states that he was advised by Highmark that the payment was never received and that his policy was in danger of cancelling. The member would like assurance that the payment has been applied to his policy.I have reviewed the member’s account and have located the payment he made on June 25, 2015, via telephone. There was an error in the processing of the payment, and it was not posted to his policy. The payment has been posted, and the member is now paid to August 1, 2015.There was also a discrepancy in the amount he was being invoiced. The member is eligible for an Advance Premium Tax Credit (APTC) in the amount of $112.00 per month. His invoices for July and August did not include this APTC. This has now been corrected and there will be an adjustment of $224.00 on his next invoice which will generate around August 8, 2015.If you have additional questions, please contact me directly.Linda S[redacted]Appeals CoordinatorPhone: [redacted]

Review: I attempted to switch to a new recurring credit card payment method online however the incorrect card was billed two months in a row resulting in nonpayment for insufficient funds. I was able to obtain my monthly prescriptions with no issue therefore didn't realize my payments were late. When I realized my payments were behind I immediately called in and made a 3 month payment on 7/28/14. Highmark accepted that payment and I assumed my health insurance was still active. On 8/19/14 I attempted to pick up a prescription and was told that my insurance was cancelled so I immediately called Highmark to find out what the problem was because I made my payment to bring my account current. They said because it was so late they could not reinstate it. Now I am left with no insurance and all of the monies I've paid towards my deductible are meaningless. I feel like they should not have accepted my payment in July if they weren't going to reinstate me. How convenient for them to deny me after I've almost met my deductible. Since they accepted my payment on 7/28/14 I feel they should honor my insurance. I can't even get a new insurance policy with them right now because I'm out of the enrollment period. I was paying $367 a month for platinum health care and now am stuck with medical bills and prescription costs that should have been taken care of by Highmark. They have stated they will reimburse me the last 3 month payment I made but said it would take up to 2 weeks to process, which is absolutely ridiculous. They accept my payments right away and should reimburse me right away as well.Desired Settlement: My desired solution was to continue with my policy since I made my payments and my account was paid up in full. I have had to pay for doctor visits out of my pocket and also prescription costs and would like to be reimbursed for the difference that they would have otherwise paid if they would have kept my account. If this is not possible I want my refund immediately and would like the ability to start a new policy and have the monies I've paid towards my deductible applied toward that new policy

Business

Response:

Case ID: [redacted]

I received a second bill on a service that has already been paid. I called and found out that that laboratory had been audited and [redacted] of been underpaid. I later got a letter from HighMark apologizing for the confusion or frustration I might've experienced as the result of a reprocessed claim. I called HighMark to ask why I had not been notified before being rebilled. There was no explanation. According to the high Mark representative I spoke to - there is no one to whom he can pass on my concern.

Review: After several phone calls and talking to several different people my issue still to this date hasn't been solved. It started when I got a new health policy with this same company. I called in December to get my first premium set up and they were "supposed" to transfer the credit from the old policy to the new policy and I paid the remaining balance on the new policy...this making me set to go for January. I then started getting bills is January stating that I owed $80+, so I called. The person I talked to told me that they hadn't transferred all the money to the new policy and if I didn't make the $80+ payment that day then my policy would be shut off, so I made ANOTHER payment that day. Funny thing is my policy still got shut off and it took them weeks to get it straightened out and I had to pay out of pocket for prescriptions and Dr visits. So I called again today to see about the refund I am supposed to be getting and now they are saying I owe $40 on the policy, even after I make two $127.66 payments a month. I am beyond mad at this point. I shouldn't have to wait for a refund for money that I shouldn't of had to pay in the first place.Desired Settlement: I want this issue resolved and my refund taken care of. I think they should realize that this is people's health care they are messing with.

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 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]

Review: on 11/25/2014 I contacted Highmark Blue Shield in reguards to them messing up payment information with my account that ended up cancelling my healthcare plan. Our office has recorded phone lines and per the attorney generals office under Title 18 Chapter 57 we are legally allowed to record calls as long as we inform the other party the call is recorded. When talking with the Highmark rep (Mike) he informed me my call was being recorded, I also informed him our call was recorded. After I told him that he demanded I stop recording the call. I questioned him on why and he just stated I had to stop the call or he would hang up. I stopped the call he placed me on hold for 2-3 mins then returned and said since the call was at one point recorded he couldnt talk to me and when I began to ask why again he hung up on me. I have lodged a formal complaint with the PA AGs office and the FCC.Desired Settlement: Contat needs to to be made with this company and inform them they are in violation of the law and need to change how they handle such matters.

Business

Response:

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

Review: Blue Cross Blue Shield has denied coverage on a health care claim based on a code. Their explanation for denial was that they considered the procedure "Experimental in nature." However, on my Explanation of Benefits it clearly shows that they have approved another item with the same code. I have contacted their hotline and they give the same explanation. They have not provided any scientific evidence of why this is considered experimental. I have wrote several emails and sent a certified letter to the company to try to discuss this matter further and they have not responded.Desired Settlement: I would like for BCBS to cover my health expense and to change their business practices about contacting policy holders.

Business

Response:

This is in response to your inquiry sent to us regarding the member identified by your case ID[redacted]The member received an Explanation of Benefits (EOB) statement, for a claim that showed twoseparate services each with different charge amounts, but listed as the same type of service. Thisclaim processed one charge as an eligible service, but denied the other charge. The membercontacted our Customer Service Department for an explanation was advised that although theservices were both listed on the statement as the same type of service on the statement, therewere different procedure codes attached to each service on the claim.While our EOB statements for professional claims list specific procedure codes for servicesrendered, facility claims, such as the one in question, show revenue codes on our statements.These revenue codes are categorized by general service; however, a more specific procedurecode may be required for processing to determine benefits and pricing. The revenue andprocedure code is submitted by the facility to Highmark, and is present on our processingsystem, but both codes aren’t shown on our statements. However, Customer Service and/or thebilling facility may provide this information to the member.The denial of the service found in this facility claim was determined to be experimental andinvestigational, according to our Medical Policy, thus rendering the service ineligible forcoverage. This specific policy bulletin was recently provided to this member, along with aresponse to his letter received in our Law Department.Customer Service is the most appropriate source of information pertaining to claims and benefits.We respectfully request that this member continue to utilize this service for questions.

Review: My wife, [redacted] selected the Highmark Balance Blue PPO 1000 policy through the Affordable Health Care website on 04/10/2015 and was transferred the the Highmark website to make the first payment which was done. We were informed after selecting that policy that we should receive the booklets within a couple of weeks. We never received the health or prescription drug booklets and have called back a couple of times and were told again that we should received them shortly, which as of today 06/15/2015 we still have not received them.Desired Settlement: Send us the booklets for the the policy she selected, Balance Blue PPO 1000.

Business

Response:

June 19, 2015 Revdex.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. In the complaint, the member’s husband states that she did not receive a benefit book for her policy after enrolling in the Balance Blue PPO 1000 on April 10, 2015. He states that they called and requested the books, and were advised she would receive them within a couple of weeks, but they were never received. Upon review of the account, there was a request made on April 30, 2015 for the Enrollment packet. However, this request was cancelled in error on May 5, 2015. I placed a new request in the system today and she should receive the packet within seven to ten business days. I will follow up with the member to confirm of receipt of the enrollment packet. If you have additional questions, please contact me directly. Sincerely, Linda S[redacted] Appeals Coordinator Phone: [redacted]

Consumer

Response:

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,

Business

Response:

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]

Review: Highmark Insurance is incorrectly denying claims made by health care providers I have seen this year. Highmark acknowledges that my account is paid in full (and in advance) but their claims system rejects claims to my account on the grounds of "account not paid". Highmark acknowledges that the denial of claims is a result of a confusion within their internal computer systems.

I have contacted Highmark about this multiple times. Despite repeated promises by customer service agents to resolve the issue, claims to my account are still being denied on these inaccurate grounds more than 3 months after the first denied claim and multiple requests to rectify the situation.Desired Settlement: I need Highmark to resolve its internal systems issue regarding my account immediately, so that my credit rating and credit history is not damaged by bills from health care providers going into collections. Highmark has repeatedly acknowledged that I have paid my account in full and that they should be honoring these claims. I need Highmark to immediately resolve the situation and honor the financial obligations that I continue to pay for.

Business

Response:

June 15, 2015 Revdex.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 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]

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 IF the invoices are generated correctly and at the correct amount as noted on my healthcare.gov agreement.Thanks to [redacted] in W VA for sleuthing out the problem and to all who have addressed it for a resolution.

Review: I subscribed to freedom blue ppo in dec. 2015, to become effective jan 1st 2016.

I made a payment for the month of jan. at this time. when I received the first billing statement for the month of feb. it said I owed for the month of jan.

after repeated (at least 7 calls ) I still have not been credited with my payment. I faxed a copy of the cancelled check as proof of payment per their representatives instructions. after every phone conversation I was assured someone return my call. not one return call.

I was told the payment was misdirected to the wrong department. After a whole month of aggravating phone calls I still have no solution in sight.Desired Settlement: credit my lost payment to my account

Business

Response:

Member: [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 Freedom Blue PPO on February 18, 2016 regarding complaint ID #[redacted].Ms. [redacted] is filing a complaint against Freedom Blue PPO regarding her premium payments. She states she sent in a payment for January that was never applied to her account, and her invoicing indicates she is one month in arrears.I have investigated this issue and found that there was a payment received on December 11, 2015 via check # [redacted] in the amount of $279.50 that was misapplied to another member’s account. This other member did not have an active policy, and so the payment was refunded to that member in error. The amount of $279.50 in lieu of this payment has been removed from the balance of Ms. [redacted]’s account on February 25, 2016. Her account now reflects credit for this payment as well as two additional payments: one in the amount of $559.00 received February 5, 2016 and one in the amount of $279.50 received February 23, 2016. Ms. [redacted]’s account is paid through March 31, 2016 as of the writing of this response.I apologize for any confusion this issue has caused. If Ms. [redacted] has any additional questions or concerns, she may contact a Freedom Blue PPO Customer Service Representative at [redacted] Monday through Sunday 8:00 a.m. to 8:00 p.m.Sincerely,Jennifer B.CMS Complaint Specialist

Review: MY HUSBAND AND I APPLIED TO THE OBAMA CARE AND US BEEFED WITH THIS COMPANY, NOT KNOWING BECAUSE THEY US PUT IN POLICIES SEPARATE COBRANDONOS AROUND THE CENTRAL MAGNIFICENT OF $16 BY MY AND $134 FOR MY HUSBAND, THE POLICY BEGAN ON MAY AND WE PERFORMED THE FIRST PAYMENT, THAT SAME MONTH TRIED TO CANCEL THE POLICY ALREADY NOT COULD PAY ABOUT $150 A MONTH AND NOT US THE ALLOWED [redacted] TO ONLY MARKET SAFE HAD THE POWER TO DO SO. WE REQUEST THE RETURN OF THE PAYMENT THAT PERFORMED BY MY HUSBAND BECAUSE IS DETERMINED THAT THERE EXISTED WAS A MISTAKE TO PUT US IN SEPARATE POLICIES WHEN WE WERE LEGALLY MARRIED, AND NOT HAVE WANTED US TO DO THE REFUND.Desired Settlement: I WANT MY [redacted] MONEY OR MAKE ME A CREDIT TO MY ACCOUNT OF HIGHMARK

Business

Response:

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

ID number you provided.

The consumer is requesting the refund of’ the premium payment for the month of May

2014 for a policy that covered their spouse because they allege there was an error in their

enrollment into a Preferred Provider Organization (PPO) policy through the Federally

Facilitated Marketplace (PPM).

Our research shows that Highmark received an enrollment file from the FFM for the

consumer and their spouse on March 26, 2014. This PPM enrollment file enrolled the

consumers in separate individual policies effective May 1, 2014, Highmark received a

new enrollment file from the PPM on May 22, 2014 that cancelled the individual policies

effective July 1, 2014, and created a new joint policy for the consumer and their spouse

effective July 1,2014. The spouse’s policy was cancelled by Higbmark effective June 1,

2014 due to nonpayment of the premiums.

Highmark cannot refund the May 2014 premium payment submitted for the spouse’s

policy as the policy was active. The consumer may contact the PPM at [redacted]

and request the effective date for their policies be changed.

If you have additional questions, please contact inc directly.

Sincerely,

Executive/Legislative Inquiries

Review: I purchased a healthcare policy from the ACA exchange and provided by the Highmark Blueshield company. The specific policy is called the comprehensive Care Blue PPO 500. During the process of selecting this policy, I was allowed to review a document called the summary of benefits. This document clearly explains on page 4 that generic drugs from a pharmacy will cost $5 for up to a 90 day supply. After purchasing the policy a detailed contract was available for my review. This contract contradicts the summary of benefits and stated generic drugs are $15 for a 90 day supply. However this contract was not available until after my purchase.

I was told by the customer service representative before and after purchase that they would honor the $5 price. Now they will not.Desired Settlement: Honor the terms of the summary of benefits and provide generic drugs at $5 for a 90 day supply.

Business

Response:

Review: I contacted Highmark on April 6, 2015 wondering why I did not receive an invoice for the billing period 4/1/15 to 4/30/15. I was informed that my insurance was cancelled, reason unknown as my payments had been made. After being placed on hold repeatedly, I was informed that no payment was received 11/2014. After stating that I had all my previous invoices and cancelled checks in front of me and bring placed on hold longer, my payment was found. I was then transferred to customer service to see how to get reinstated. I was told a request to reinstate would take 2-3 weeks or 7-10 business days. After practically 2 months and never hearing anything and thinking another error was made, I received an invoice on June 1 for $532.17 due before 6/8, not even knowing I had been reinstated. I then called Highmark to cancel my insurance and get an explanation of the charges, as I no longer want to do business with them. I was redirected to the marketplace to cancel, I was also informed by the marketplace that they had no record of my insurance being cancelled before today. Upon calling back for an explanation of the charges, I was informed that my insurance was reinstated 5/21/2015 and I would still be responsible for paying for April, May, and 16 days of June. I never received any correspondence with regards to cancellation or reinstatement, which is ridiculous and I will absolutely not pay for months of service that I did not receive due to an error on Highmark's behalf.Desired Settlement: Return my account balance to $0 as it was in April when the error occurred, cancel insurance

Business

Response:

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]

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 cancelled service with Highmark Blue Shield in December over the phone and through the health insurance marketplace. I have received bills in January, February, and now March. Each time a bill was received I called Highmark Blue Shield and notified them that my plan with them was cancelled. They told me that I needed to talk to healthcare.gov to cancel my policy because that's who I signed up through. Healthcare.gov confirmed my policy cancellation and told me to contact Highmark Blue Shield. Bottom line is Healthcare.gov tells me that my policy is cancelled, Highmark Blue Shield tells me that Healthcare.gov is telling them that my policy is not cancelled.Desired Settlement: Any amount charged to me to be reversed. Any negative reports to credit agencies to be recanted/removed.

Highmark is attempting to charge me twice for blood work, once for the preventive tests and once for the [redacted] test. That is illegal and I will not pay twice.

Highmarks brochure clearly states that [redacted] is covered by a [redacted], that is what I had done. So why are they not covering that? Attached is the research from WebMD that clearly states the test I had done was a [redacted].

Review: Saturday January 31, 2015 I followed instructions on first bill received to pay first premium for health insurance for myself and my daughter to go to Highmark website [redacted] premium amount is $133.87 chat rep on website informed me that first payment has to be paid over phone mon through friday. On Monday Feb 2 I called the highmark customer service [redacted] located on my bill, the representative took my $133.87 over the phone gave me a confirmation number and said I will receive insurance cards in next few days and that I had active insurance now. The $133.87 was removed from my bank account the next day without incident and a few days later I received the insurance cards and a welcome kit.

February 26 2015 I received a letter from Highmark dated February 20th that my Health Insurance has been cancelled "due to non-payment of the required premium" I went to the Highmark website and it didnt recognize me as a member. I contacted my bank and my bank confirmed that Highmark was paid without any incident on February 3 2015 in the amount of $133.87 I called Highmark customer service explained situation that I paid them just fine and they cancelled my insurance for it. The representative said she couldn't find any reason why it would be cancelled either and that she would escalate information to reinstatement department and would call me back in a few days.

March 3 2015, called customer service again because I had not received a call back yet. Spoke with Kristen and she stated that she could see payment was paid within timeframe, that payment was not returned and that it was escalated to reinstatement department and might take a few more days. I told her I wanted to pay my March premium while they corrected my account from the February payment I made to them and she stated they can't take any more premium payments from me until the February payment issue is resolved. I explained to her that I had prescriptions for myself that I needed to pick up and that I don't have any insurance now and will be forced to pay full cash price. She said it wouldn't take much longer for the reinstatement and her advice was to make sure I don't spend any money that I will need to pay Highmark premiums. Easier said than done when taking daily medications but I did skip my medication doses waiting for them to quickly resolve the issue.

March 12 2015, still have not received any information from Highmark, I called again. I spoke with Amber, she stated that reinstatement is still open and being investigated and they would call me when it was resolved and it shouldn't be much longer. I never received any calls or anything in the mail or by email. I called again in beginning of April, spoke with Bobbi and she said I should receive something in the mail with the determination. I again voiced my concern that I have now had to pay cash for my [redacted] blood work, for my daughters doctor appointment, and for prescriptions for me and daughter and they have created a situation that I was not prepared to be put in because they weren't able to process a payment effectively. Although se understood my concerns she stated that I would have to wait for the new bill and we both agreed that the new bill would be for $267.74, for March and April because they were already paid $133.87 for February.

On May 2 2015 I received a bill stating the amount due to reinstate was for $401.61 due before May 17 and current amount due was $535.48. Highmark has now wanted me to pay the February payment that they already received again. Needless to say I have lost all confidence in Highmark to not only process payments received correctly let alone provide competent coverage.

I began writing letters to them instead of calling customer service because it was now clear that front line reps didn't have any ability to handle billing complaints themselves or have a situation quickly resolved. I explained in the 3 letters that I wrote them over the next few months of the issue that has occurred, that I no longer want to be involved with their institution and I wanted a refund of my February payment they received of $133.87 for which they provided absolutely no product for and instead only created a financial disability for my family and created a dangerous situation where my and daughter and I do not have any health coverage.

The only response I received were two form letters. One dated September 8 2015 stating that my policy "was terminated on 9/11/2015 due to non-payment of required premium." The second letter dated September 14 2015 states, "your policy has been terminated effective 4/01/2015 due to non-payment of required premium." "Please note that this termination date reflects your last date of coverage for which premium payment was received, plus an additional month of coverage through the last day of the 1st month of the grace period. You remain liable for your share of the payment of the premium during the time coverage was in effect during this grace period."

Effectively they now (in September) admit they did receive my premium payment in February but they're keeping it even though at no time was I ever given an active product and want me to pay them for the months they spent "investigating" the payment they now in September acknowledge receiving but February though August didn't acknowledge receiving. Basically thanks for giving our company $133.87 in February for a cancelled policy and you're now responsible for paying the erroneous bills we spent months working hard to create for you.Desired Settlement: I want my $133.87 returned to me immediately. And I will not be held responsible for any further payments. I gave them $133.87 they gave me a cancelled policy. At this point it's a very simple resolution for what Highmark has put my family through this year.

Business

Response:

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]