Integrated Equity Management Inc

RE: Complaint ID ***Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 17, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-cornpIaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Ariell A*** Staff Attorney UPMC Health Plan

RE: Complaint ID ***
Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 12,regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please, do nothesitate to contact me at *** ***Sincerely,Ariell A*** Staff Attorney UPMC Health Plan

RE: Complaint I* #***ear Ms***:UPMC Health Plan, inc("UPMCHP") has receive* an* reviewe* your letter *ate* May 5,2017, as well as the accompanying complaint,We thank you for bringing this matter to our attentionUPMCHP takes all potential privacy an* security concerns very seriously,
an* is currently investigating the possible occurrence of theinci*ent *escribe* in the complaintShoul* results of the investigation substantiate the concerns expresse* by the complainant/ UPMCHP will contact the complainant *irectly regar*ing any implicate* resolution,.If you have any further questions or nee* a**itional information, please *o not hesitate to contact me at ###-###-####.Respectfully Submitte*,Cha* *, Greenwal*UPMC Health Plan***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***
I find that their response which was sent to me directly has addressed many of my concerns. Regardless of whether I find their responses satisfactory or not, it is appreciatedI am not entirely satisfied that UPMCHP will effect any real change that will avoid for other customers the issues that led to my complaint I will present any further concerns directly to the company as they have asked that I forward marketing material that I found questionable to themThe wording of said marketing material was part of my previous complaintA copy of the marketing piece has been attached and may be forwarded to UPMCHP. After which, the Revdex.com may close this complaintRegards, *** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Hello, In accordance with the letter received I am updating you on recent contact with UPMC Health plan.On 12/21, I received a call from their “800” number.I was told that because of a “glitch” in the system and failure to notify me.That I did not have insurance, that it had been cancelled, I would be reinstated.My reference number for this was ***In order for the reinstatement to be completed I would need to make December paymentWhich I did, $275.58, confirmation number for that ***I held on the line while I was reinstated, or thought. Today, 12/28, I went to the pharmacy.No insurance.Please call UPMC, which I did and was told I was never reinstatedAnd it was denied.(the reinstatement)So, now I am out two payments of $275.58 And have yet to be formally notified that I do not have coverage. Is this for real? Sincerely,*** *** ***

RE: Complaint ID ***Dear Ms, ***.UPMC HealthPlan, Inc("UPMCHP") has received and reviewed your letter dated July 1, 2017, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-compIaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Ariell A*** Staff Attorney UPMC Health Plan

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Re; Complaint ***Mrs***,In response to UPMC response to my complaint, I am not sure how it was taken out of context from a complaint against UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA to UPMC Health Plan legal H1PAA and PHI.First of all, I was not requesting anyone's personal information or medical records from UPMCMy complaint was against against UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA for sending junk mail [advertisements] to my home for people that don't live at my home and never have lived at my homeThe names are Irene *** and *** * *** ***Once again UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA needs to stop sending me advertisements for an Irene *** and *** * *** ** at my address [above]No such people have ever lived at my house.Sincerely, *** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me I am a member of UPMC, to prove this, I have ID#: ***My name on my insurance card reads as *** * ***I would like this issue resolved as it is hurting my credit score
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint.? For your reference, details of the offer I reviewed appear below
Regards,
*** ***

RE: Complaint ID ***Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 27,regarding Complaint ID ***.The above-referenced complaint did notinclude a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Ariell Antonio Staff Attorney UPMC Health Plan

RE: Complaint ID #*** Dear Ms, ***:UPMC Health Plan, Inc, ("UPMCHP") has received and reviewed your letter dated January 4,2018, as well as the accompanying complaint.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint, However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any further questions or require additional information, please do not hesitate to contact me at ###-###-####.Respectfully Submitted,Chad *G*** UPMC Health Plan

UPMC Health Plan, Inc(“UPMCHP”) received and reviewed your letter dated May 11,2018, as well as the accompanying complaint.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information, Without a HIPAA-compliant authorization,
UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and,, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attention*Should you have any further questions or require additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Lakshmi D*** Staff Attorney UPMC Health Plan

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me.?
*** *** *** *** *** ** ***November 20, 2015Revdex.com *** *** *** *** *** *** *** *** *** ** ***Re; Complaint ***Mrs***,I got an email about a response from UPMC about my complaint and I responded rejecting their response.A little while later I received a letter from UPMC that is acceptable and I would like to now dose the complaint.Thank you.Sincerely,*** ***

#***.To: Revdex.com Complaint has been fully resolved.Thank you

RE: Complaint ID ***Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated July 22,2017, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization- that would allow UPMCHP to disclose protected health
information, Without a HTPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Ariell A*** Staff Attorney UPMC Health Plan

UPMC Health Plan, Inc, (UPMCHP) has received and reviewed your letter datedMay 9, 20x8, as well as the Authorization to Release Health Information signed by the Complainant on May 7, Please accept the following as the response .of UPMCHP to the complaint filed at the above-captioned file number.The Complainant is enrolled in a UPMC Small Business Advantage Gold Preferred Provider Organization (PPO) plan, a full insured employer group plan provided by UPMC Health Options, Ine, The Complainant's current plan became effective April 1,Prior to the current plan year, the Complainant was enrolled in the same PPO plan from April I, 20xthrough Match 31,2018.The Complainant alleges in his complaint that UPMCHP has failed to acknowledge or process certain out-of-network claims he submitted for reimbursement over the previous eighteen monthsThe Complainant, requests that UPMCHP pay all outstanding claims submitted in and provide a resolution to ensure that future claims submissions are processed and paid in a timely fashion.According to the Complainant's and Certificates of Coverage ("COC"), members may be required to self-submit claims for payment of certain medically necessary covered services provided by non-participating providersIn order to properly submit a claim for reimbursement, members must fully complete an Out-of-Network Care Claim Form ("Claim Form") and mail it, along with proof of any payment already made/to "Claims Department, UPMC Health Plan, Inc., P.OBox *** *** ** ***", Members are also welcome to submit the? documentation to UPMCHP via fax to ##########.Regarding proper completion of the Claim Form, The Complainant's COC further advises, "a request for payment of a claim will not be reviewed and no payment will be made unless all of the, information [identified in the claim submittal instructions] has been submitted to UPMC Health PlanUPMC Health Plan reserves the right to require additional information and documents, if necessary, to support your claim/'Moreover, page one of the Claim Form instructs, "Both sides of this form must be completedIncomplete forms will delay payment." Thus, a member's failure to submit all necessary information to the Claims Department at the address or fax number listed above may result in significant delays in UPMCHP's processing of self-submitted claims.UPMCHP's records indicate that the Complainant first filed an internal complaint on April 25, to dispute UPMCHP's delay in processing claims he submitted for services received from an out-of-network provider between November 29, and March 30, During its investigation into his complaint, UPMCHP discovered that the Complainant failed to mail the form to tire attention of the Claims Department as directed by both his COC and the Claim Form instructionsThe Complainant also neglected to fully complete the Claim Form, leaving both the "claim information" and "assignment" fields blankFollowing its review and identification of the above errors, UPMCHP was able to resolve the Complainant's-complaint and process the claims at issue in accordance with the terms of his benefit plan.The Complainant filed anofixer internal complaint on September 12,to dispute UPMCHP's delay in processing claims he submitted on July 27,for services he received from the same out-of-network provider between April 3,and June 29, ¦2017, Once again, the Complainant's submission contained both an address error (mailed to "UPMC Health Plan, P.OBox ***" rather than "Claims Department, P.OBox ***") and incomplete claim form ("claim information" and "assignment" fields left blank)Upon completion of its review of the complaint and identification of the errors in his claim submission, UPMCHP advised the Complainant by letter dated October 6,20xthat tire claims would be entered into its claims processing system for possible reimbursement in accordance with his benefit planThe claims at issue were then paid on October 27,2017.? On April 9,2018, the Complainant filed an internal complaint with UPMCHP regarding the processing of Claims Forms submitted on February (for dates of service between October 2,and November 28/ 2017) and March 13/ (for dates of service between December 4,and February 14/ 2018)Following a thorough investigation, UPMCHP responded to the Complainant by letter dated May advising-him that the claims for out-of-network services rendered between October and November 28,were reimbursed on January 19,2018, and the claims from December 4,through February 14,20xwere currently in process for reimbursement following a delay due to the Complainant's failure to include proof of payment with his submissionIn its May response, UPMCHP also reiterated the proper process for self-submission of claims in an effort to help the Complainant avoid delays in the processing of any future claims submitted for reimbursement.UPMCHP understands the frustration this situation has caused, but maintains that the Complainant's self-submitted claims have been processed in accordance with the terms of his benefit plan upon receipt of all required claim and payment information.Respectfully Submitted, UPMCHealth Plan, Inc.?

RE; Complaint ID ***Dear Ms***:On December 21, UPMC Health Plan, Inc("UPMCHP") received additional correspondence concerning UPMCHP's response to Complaint ID***'Although an authorization form was provided with the December 21st correspondence, it did not contain the signature of the individual who is the subject of the complaintAs such, without a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-#### or Gail M***, Administrative Assistant, at ###-###-####.Sincerely,Ariell A*** Staff Attorney UPMC Health Plan

Re: *** ***Complaint ID: ***Dear Ms*** ***:UPMC Health Plan, Inc(“UPMCHP'’) has received and reviewed your letter of January 14,2016, as well as the accompanying complaint tiled by *** *** at the above-captioned file number.Mr*** complains about the denial of
reimbursement for medicationMr*** has prescription drug coverage under the UPMCHP *** *** ***UPMCHP established prior authorization requirements and quantity limits on certain medications to comply with Food and Drug Administration guidelines and to encourage appropriate prescribing and use of such medicationsOur records show that Mr*** repeatedly attempted to fill a prescription for *** * ** ** on September 3, through October 19, Coverage was denied because *** requires prior authorizationOn November 2, 2015, UPMCHP received medical records demonstrating that as of October 27, 2015, Mr*** met the prescribing criteria, and the requested medication was approved indefinitelyUPMCHP attempted to contact Mr*** by telephone on November 4, 2015, to inform him that the authorization was approved effective November 2, 2015, but was unable to reach himUPMCHP backdated the authorization to October 27, (the day Mr*** was found to meet criteria for approval).On November 19, 2015, Mr*** contacted UPMCHP requesting reimbursement for out of pocket expenses incurred up to the date of approvalA UPMCHP representative provided him with instructions to file a claim.A claim for reimbursement was received on December 16, 2015, for dates of service commencing on October 5, However, because this date of service was before October 27, 2015, the request was denied.While UPMCHP is sympathetic to Mr***’s complaint, UPMCHP is unable to reimburse him for medication purchased prior to meeting the medical necessity guidelines, which in this case, include the required screening performed on October 27, 2015.Thank you for bringing this matter to our attentionShould you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely,Nancy ** F* Esq.UPMC Health Plan

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint.? For your reference, details of the offer I reviewed appear below.UPMC did contact me directly so as not to violate my privacy as it relates to healthcare or health insurance issuesUPMC did address my complaint in their internal response as well as they the letter sent in response to the Revdex.com complaintThey? admitted customer service representative on Dec15th, lacked clarity in answering my questions about the ramifications of non-payment of premiumsUPMC also offered in their original internal response to reinstate coverage for if past due premiums were paid for But both of those things happened prior to my submitting my complaint to the Revdex.comUPMC's staff attorney sent me a letter which I received shortly after the one sent to the Revdex.com about this matterThe letter reiterates UPMC's admitting lack of clarity on the issue and the offer to reinstate coverage if premiums were paidHowever, the? deadline to comply? with that? resolution had passed and I was unable to may payment prior to itThus, barring any further review by UPMC or? a directive from any outside agency such as the FMM or the PA? Department of Insurance or through legal means, I remain without coverage.? I appreciate? both the admission of lack of clarity and? additional time given for? reinstatement if past due payments were made to UPMCHowever, ? I have continuing issues with UPMC on the matter including the publishing of marketing piece that is? contrary to the reality of UPMC's actual rules and guidelines, continuing pattern of misleading, incorrect and ever changing information when talking to a CSR one day and then going over the same issue or issues with another CSR and being told something completely differentI also have issue with UPMC and the FMM website presenting contrary information on the subject of grace periods while the issue was unfoldingHowever, it appears that both UPMC and the FMM website now present similar information on the subjectI also have issue with UPMC as to when they inform past due customers as to the ramifications of non-payment for a new policy yearAdditionally, I have issues with how the complaint process works at UPMC such as not having an email address to submit documents, clear information on deadline to submit documents as well as not receiving clear information on how many levels of internal appeal UPMC offers and clear information about the availability of transcripts of customer service calls if requested by a consumerMost of these matters have been presented in a complaint filed with the PA Department of Insurance and may be filed with the FMM
Regards, *** ** ***
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