Kaiser Permanente of Washington

I am writing in reponse to your November inquiry on behalf of Mr*** *** received by Group Health Cooperative
We understand Mr*** expresses frustration with the on-line payment website and changes in the premium amounts due based on changes to the applicable tax credits for
Mr***Mr*** is enrolled in a individual & family Core Silver HSA plan, Purchased through the Washington Health Benefit Exchange (HBE)We apologize for any inconvenience this may have caused
A review of Mr***'s premium history confirms the following:
Group Heath was notified by HBE that there was a change to Mr***'s tax credits effective to July 1, The appropriate premiums adjustment was updated to the Softheon environment on September 25, Invoices for premiums also reflected this change with the October release of billing statements.
Group Health did complete a full account analysis that was mailed to Mr*** as of November 21,
That account analysis does illustrate payments from October through December premiums
As of the date of the most recent account analysis, the outstanding balance is $for the November and December premium periodsThis is the per month premium rate of $after the tax credit adjustment indicated by HBE
At this time, the on-line account history only shows the current bill and the previous payment made to the accountWe appreciate the feedback regarding this; we will continue to look for ways to improve the member experience and this information will be helpful for those considerations
The Group Health Membership department confirms invoices were mailed to the address on file for Mr*** to advise the balances due on the following dates: 12/21/2015, 01/12/2016, 02/11/2016, 03/11/2016, 04/11/2016, 05/11/2016, 07/07/2016, 08/11/2016, 09/06/2016, 10/06/2016, 11/09/
For those members who enrolled in Group Health plans through the Health Benefit Exchange (HBE), the on-line payment is through a separate web location than their patient accounts paymentsGroup Health has an agreement for the HBE premium payments to be managed through a contracted provider, Softheon, but a link to this page is located in multiple areas within the Group Health pagesFor convenience we have included the link below along with the payment options available to members wishing to make premium payments for their HBE coverage.
Making a One-Time Payment:
Members can make a one-time payment by logging into their account on ghc.softeon.com or by selecting the Quick Pay option using the subscriber's ID number
The member does not have to create an account to use the Quick Pay option
We are not able to see the reason for failed payments, however members should receive immediate notification if the card number, security number, or expiration date are not valid
Members will not be able to cancel a payment once they have approved it
Setting Up a Recurring Payment:
Recurring payment is based on the amount the member chooses and will not change, evein if the member's balance or subsidy amount changes
Recurring payments will withdraw the scheduled amount, even if the member has no balance owed since it is based on the amount they scheduled
Members can set up more than one recurring payment for their monthly premiums.
Payments can only be scheduled for the 1st and 15th of each month
Payments need to be scheduled or called one business day before the scheduled date or it will not take until the next monthSoftheon will list the first day of withdrawal at the time the member is setting up the recurring payment
We are not able to see the reason for failed payments, but members will receive an e-mail for failed recurring payments with information detailing the declined card
Recurring payments will not withdraw on the date they set up the payment, but on the date designated for the recurring payment
Pay by phone with a credit card hours x days a weeHave the bill handy; you'll be asked for the digit Group # along with the preferred method of payment: Visa, MasterCard, Discover, and American Express are acceptedGroup Health Cooperative plans call 1-244-632-to use this payment service.
Check Payment with or without coupon - GHC (HMO):
Mail in the payment with the payment coupon to the return envelope sent with the premium statementGroup Health Cooperative ** *** *** *** ***, ** ***-***
Pay via your bank's online bill pay servicePlease provide payee information (Group Heath Cooperative/Options), your digit Group #, your digit subscriber #, and P.OBox payment address provided on your premium statement (see above P.OBox address noted)
Should Mr*** need any assistance with these payment methods or have payments that do not match the account analysis, our Customer Service call center is available to assist at 1-888-901-
Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at ***-***-***
Sincerely,
Rebecca H**
Health Plan Administration

I
am writing in response to your June 12, inquiry on behalf of *** *
*** received by Kaiser
Foundation Health Plan of Washington. We
understand Ms*** submitted a complaint regarding difficulties she
experienced with coordination
of benefits for
services. She also
indicated she submitted a complaint to the Washington
Insurance Commission that was still under review at the time of this
complaint. We apologize
for the negative experience Ms*** has encountered with this
situation. Originally,
Kaiser Permanente’s Coordination of Benefits (COB) Department was notified by Amerigroup
that Ms*** had been enrolled with them since May 1, and her coverage
was still
activeAmerigroup would be considered primary as she was enrolled with them
longer; Ms. ***
was enrolled at Kaiser Permanente effective October 1, 2016. After
further investigation we have confirmed with our Coordination of Benefits
Department that Ms. ***’
account was set up incorrectly with the information we received on May 9,
from ***’
account was set up incorrectly with the information we received on May 9,
from secondary
insuranceMs*** joined Amerigroup as an Apple Health of Washington
(Medicaid) recipient
on May 1, 2014; she has changed to Molina Healthcare as of May 1, 2017. We have made the
appropriate corrections to Ms***’ account and now reflect Kaiser
Permanente as primary insurance
and Amerigroup as secondary insurance. On
June 16, 2017, MsParson’s claims were reprocessedWithin10-business days,
an Explanation
of Benefits (EOB) will be mailed to Ms*** with the corrected payments for
all applicable
claimsThank you again for taking the time to bring this to our attentionIf
you have any questions
regarding this matter, you may reach me at 206-630-

Revdex.com response is attached
I am writing in response to your September 7, inquiry on behalf of Mr*** *** received by Group Health Cooperative. We understand Mr*** expresses frustration that his Individual & Family plan coverage was cancelled without notice despite
on-going payments made toward his premiums, and that he did not receive email notification of this termination of coverage. We apologize for the negative experience Mr*** has encountered with his premium payments and continuing medical coverage as a result. I have shared your concerns with our Membership department, and have confirmed the following for this memberOur records indicate that multiple balance due and delinquency notices have been mailed to Mr*** at the address matching that listed in his complaint to you. These notices for balances outstanding in full or in part, were mailed on the following dates: 09/15/2015, 10/15/2015, 11/13/2015, 12/15/2015, 01/15/2016, 02/16/2016, 03/15/2016, 04/15/2016, 05/13/2016, 06/15/2016, These notices state the following: Failure to make payment in full will result in this account being terminated for delinquency. Any payments made to this account that are less than the total amount due will reduce the outstanding balance, but will not prevent the cancellation of the accountTermination notification was subsequently mailed to Mr*** dated 7/15/2016. Mr*** coverage has been reinstated in anticipation of the payment in full of the outstanding account balance to be paid on or before 9/15/2016. As of the date of this letter, that balance is still outstanding.*Due to privacy and security of protected information for our members, both delinquency and termination notices are mailed to the address on file and would not be sent by email. Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at ***.Sincerely,Rebecca H** Health Plan Administration

Dear Ms***:I am writing in response to your April 15, inquiry on behalf of Mr*** *** received byKaiser Foundation Health Plan of Washington Options Inc.We understand Mr*** has expressed frustration regarding several poor experiences he has hadfor services and concerns about
staff behavior.We have been in contact directly with Mr*** and continue to work with him to identify the detailsof his complaint and specific issues we can address for himWe will then work with Mr*** tofacilitate communication to the appropriate locationsShould there be any additional complaints wewill continue to work directly with him to resolve the issues.Thank you again for taking the time to bring this to our attentionIf you have any questions regardingthis matter, you may reach me at 206-630-1573Sincerely,Rebecca H**Health Plan Administration

I am writing in response to your July 21, inquiry on behalf of Ms*** received by Group Health CooperativeWe understand Ms*** express frustration in regards to what she refers to as late billing by Group Health for her May 25, visit to our Olympia Medical Center-Urgent Care
Upon research with our Patient Financial Services department it was determined that Ms*** insurance (Regence) was billed on May 28, Regance responded with an “accepted” status; however no payment was submitted to Group HealthMs*** was sent three billing statements (3/15, 4/and 5/15/2016); payment was still not received; on June 29, the amount of $was forwarded to collectionsWe apologize for the negative experience Ms*** may have encounteredThank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at 206-901-Sincerely, Terri N*** Health Plan Administration

Complaint: ***I am rejecting this response because: The business apologized for my "negative experience" but made no attempt to remedy the situation.Sincerely,*** ***

Complaint: ***I am rejecting this response because:
While Group Health stated that they corrected the errors in my chart I received a bill for the other person appointment So, no it was not fixed Also I spoke to the HBE in March and they said I was insured and the new amount wasn't until April So we paid our old amount in March as should have been Sincerely,*** ***

Dear Ms***:I am writing in response to your November 4, inquiry on behalf of Ms*** ***,received by Group Health Cooperative.We understand Ms*** wishes to have her plan cover cataract treatment services with Dr.K***, received September 22, She expresses confusion regarding
the information shereceived about services with this provider and the processing of those claim.We apologize for any negative experience Ms*** may have encounteredMs***’ plandoes allow her to utilize both in-network and out-of-network providers for service and careShedid make contact with Group Health seeking providers for Cataract Treatment.A review of our records for Ms***’ contact with Customer Service reflects the following:• The focus of the conversation was Group Health providers.• The Customer Service representative gave Ms*** her in-network benefit and used theon-line provider directory for a list of providers that was emailed to her as requested.• While there was no misinformation given, we agree there was opportunity to more fullyassist with her search.• Additional information regarding Ms***’ out of network (OON) benefit and additionalguidance for utilizing contracted providers should have been offered with that call.• Within the list of providers the Customer Service representative emailed to Ms***, itappears she chose the first contracted provider, DrK***.• The listing for him did clearly say this provider is used for “limited service” and preauthorizationis needed.• Group Health Customer Service did re-contact Ms*** to advise that this provider isused for limited service and needs authorization for in network benefits
Group Health CooperativeHealth Plan AdministrationEMarginal Way SSeattle, WA 98168***800-833-TTY Relay206-901-Faxwww.ghc.orgo We also confirmed there is no authorization on file for services, and this claimprocessed correctly to her OON benefit.• To assist Ms*** with on-going care, our Customer Service team made contact with ourBellevue Eye Care center to coordinate a transition for her service that is covered as anin-network benefit.• We were able to arrange the transition of her cataract treatment to a provider within thatBellevue Eye Care Center; and the initial evaluation, follow up appointments and surgeryhave all been scheduled to occur before the end of the calendar year.Should Ms*** need assistance locating similar specialists withe preferred providerstructure of her plan, our Customer Service department can continue to assist at 1-888-901-4600.Thank you again for taking the time to bring this to our attentionIf you have any questionsregarding this matter, you may reach me at ***.Sincerely,Rebecca H**Health Plan Administration

Response to rejection is attached
I am writing in response to your September 13, inquiry on behalf of Mr*** *** received by Group Health Cooperative requesting additional concerns to be addressed. We understand Mr. *** frustration and sincerely sympathizeI spoke with Mr*** in great length yesterday eveningHe and I discussed the concerns addressed in this submitted complaint and agreed upon a payment arrangement of $(which he paid over the telephone yesterday) and the remaining balance of $407.34, to be posted by 9/30/2016; 2:00pmIt was explained to Mr*** that this is a one-time exception and if the total amount of $1,is not received by the date agreed, coverage will be terminated and he will need to reapply during open enrollmentThank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at ***Sincerely,Terri N***Health Plan Administration

Re: Consumer: *** ***
ID
Number: ***
Revdex.com Number: ***
Dear Ms***:
I am writing in response to your February 25, inquiry on behalf of Ms*** received by Group Health Cooperative.
We understand Ms*** expresses frustration due to the change in her medical and dental benefitWe apologize for the negative experience Ms*** may have encountered
In October, plan change notification letters were sent out to all current Group Health Individual & Family membersThey were sent out well in advance of the 1/1/effective date, to allow appropriate time for members to review and make any plan changesIt explained the termination of our dental contract with United Concordia, effective 12/31/and the rejoining of Delta Dental, effective 1/1/This change requires all members to complete a provided application if the member wished to continue dental coverageTo date Group Health has not received a completed dental applicationThe monthly dental premium is $I have sent an application to the home address listed in our system; if Ms*** would like coverage effective April-December, the application will need to be completed and return, by March 31.
Medical plan change information included a comparison chart (current plan to upcoming plan) and advised of all changes in the annual deductible, copayment, coinsurance, benefits and premiumsYou remain on an Individual & Family Bronze HSA plan, however as advised your Annual Deductible increased from $to $
If you have any questions regarding this matter, please reach out to me at 206-901-
Sincerely,
Terri
Health Plan Administration

I am writing in response to the follow up reply on behalf of *** *** received March 6,by Kaiser Permanente.We understand Mr*** expresses frustration related to the copays recently applied tomedication fill for his family for December 2016.We apologize for any confusion our previous response may have caused Mr***Inconsultation again with our pharmacy group and the Urgent Care visit care team, we can confirm thefollowing:• The processing of copays charged to Mr*** is a condition of two prescriptions andfilled according to the dosages for each prescription.• The first prescription for tablets, in agreement with the written dose instructions,calculated as a day supply of the medication, which applied $copay up to a day fillfor total copay $toward day supply.• With the additional prescription of tablets the copay assigned was $up to day fill.• Additional research confirms that the parent of the patient was given the prescriptioninformation as two prescriptions at the time of the urgent care service December 31, 2016.• After care notes show both prescriptions were sent to Bartels as requested.• Mr*** contacted our pharmacy group on January 9, to advise the tabletprescription was not visible by Bartels and requested the fill be sent to Kaiser PermanenteBellevue pharmacy where it was dispensed on January 11, 2017.• The medication was written as two prescriptions and filled as two prescriptions with theappropriate day supply.• The copay is correct.Thank you again for taking the time to bring this to our attentionIf you have any questions regardingthis matter, you may reach me at 206-630-1573.Sincerely,Rebecca H**Health Plan Administration

Revdex.com:I have reviewed the response made by the business in reference to complaint ID ***, however, today is Feb 25, and no pass through contribution is evident in the Health Savings AccountWhile we have GHC's attention in this matter, please have them confirm that I am looking in the right place at *** at the account number corresponding to my account
Thank you
Sincerely, *** ***

December 28, 2017*** *** *** ***
*** *** ***
*** *** *** ***
** *** ***
*** *** ***Dear *** ***I am writing in response to your December 22, inquiry on behalf of *** *** *** receivedby Kaiser
Foundation Health Plan of Washington.We understand *** *** submitted a complaint regarding a medication Kaiser Permanente hasdeclined to cover for herShe has worked for months to get this prescription, only to have it deniedwith the suggestion that she should try other medicationsShe states the alternative medicationssuggested are anti-depressants and shares that the insurance company should not presume to tellher or her doctor what drug should be takenShe is angry and requests we do what we are paid todo.While Kaiser Permanente has declined to provide benefits in whole or in part for the requestedtreatment or service, this decision does not mean that she cannot receive this medicationShe mayelect to pay the costs should she wish to do soThe medication for which *** *** requestedplan coverage has to meet certain medical criteria for use.Our review finds the request to authorize the medication was requested on November 1, anddenied for not having met medical criteriaAn appeal was submitted by *** ***’ physician toreconsider this determination on December 8, 2017, which upheld the prior denial for coverage ofthis medicationThat decision letter included information as to how and why the denial was upheldas well as alternative medications covered by *** *** plan that did not require priorauthorization(Prior authorization is a process by which a provider must obtain prior approval forcoverage of a formulary medication.) That letter also included information regarding additionaloptions, if she does not agree with the decision.While we understand *** *** desire to have this specific medication, drug coverage is subjectto utilization management and even though this medication is included on the formulary, it carriesboth a quantity limit and a required prior authorization for approval to be covered by the plan.Having a formulary allows us to offer the safest, most effective, and least costly health care possible.The Pharmacy and Therapeutics Committee (P&T Committee) develops our drug formulary, and thephysician panel from various medical specialties review medications in all therapeutic categoriesbased on safety, effectiveness, and cost, and selects the most cost-effective drugs in each class.Prescribers do not need authorization to prescribe the drug, only to determine coverage for a patient.We encourage *** *** to visit with her physician regarding any additional alternatives ofmedication steps in response to her conditionThank you for contacting Kaiser Permanente onbehalf of *** ***Should you have any further questions regarding this matter, please feel freeto contact me at 1-877-828-***.Sincerely,Rebecca H.Health Plan Administration

I am writing in response to your September 17, inquiry on behalf of Ms*** ***, received by Group Health Cooperative. We understand Ms*** wishes to have plan covered services with Dr*** *** for on-going evaluation, treatment and exams of her right kneeWe
apologize for the negative experience Ms*** may have encountered. According to Ms***’s plan coverage, services for care must be received by a contracted provider, and in most cases, services through a non-contracted provider are not covered. There are no out of network (OON) benefits for non-contracted providers under Ms***’s medical plan. Exceptions to this are as follows: The plan does cover emergency care or urgently needed services from OON providersMedical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, services might then be obtained OONMs*** shared the June 12, pain episode information in her complaint and indicates she wishes to have Dr*** provide her on-going care for pain as her surgeon for prior partial right knee replacement. Because this June episode was beyond the accepted day post-operative period, Group Health Pre-service approved one visit only for evaluation with the non-contracted Dr***He did not indicate on-going services were necessary. Subsequent authorization request for services were denied as non-contracted provider service.
An appeal is still pending for Ms*** to determine if this authorization denial is to be over-turned. Once that process is complete through outside review, she will receive written notification of that determinationAt this time, pending the appeal determination, Group Health is unable to confirm any services with Dr*** *** as plan covered services. Should Ms*** need assistance locating similar specialists withe preferred provider structure of her plan, our Customer Service department can assist at 1-888-901-4600.Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at ***Sincerely,Rebecca H**Health Plan Administration

Complaint: ***
I am rejecting this response because: it was my account #***. I was only checking those information on my daughter #*** behave. She used ABA service for years. I called the customer service department all the time to look up coverage and benefit detail all the time during I found that the (out of network) service provider was cheated on my daughter medical bill. The Service provider would lie about the service hour and coverage, and threaten me that my daughter would lost the service from Kaiser. Last year, I was able to keep the service hours running and resolve most of the issue, after I talked to Kaiser customer service. Through of the year of 2017, I verify the area from billing, service, and benefit related material almost every other month. I reported to Kaiser when I see the problem, because my daughter needed this service and over 50% of her bill was covered by her insurance. I was not a professional, but I had experience talking to the customer service department.I was very angry after I talked to Adrian. She believed the out of network service provider's job to provide these information to their customer. If they didn't give it to me, there was not Kaiser's problem. She just wanted me to hang up and stop bothering her. Surprisingly, I was not busy on that day. After she put my call on hold, I was able to wait for over minutes. The main reason of the call, was to get the updated services hours, service limitation, and some benefit information for 2018. Would that really take over minutes to get it from the system? It didn't matter if she was new or slow, but it was really shame to talk to a person like that. You know she spoke on the behave of Kaiser, it was not acceptable at all.As I talked to the manager - Steve. I told him the reason for why I called to get these information. He appreciated all my hard work. After that he simply asked me to spend more time to focus and take care my daughter at the end of the conversation. I understood it would also wasted his time if I file a complaint. He did listen to my complaint, but he was not planning to do anything after that point.You see I am spending my own time to file this complaint. It was all because of the bad quality of services from Steve and Adrian. I wasn't asking for an exciting experience from your call center. Fooling around you client isn't really an option, specially I needed this information for my family. I have a busy life too. I pay $monthly to cover my family insurance, do you think I like to waste my time and money on them? It shouldn't be an issue, since Kaiser would cover the medical any expense after we met the max-out-of-pocket. I respcted that even if the service and quality was bad, Kaiser would still be fully cover it under the contract
Sincerely,
*** ***

I am writing in response to your February 20, inquiry on behalf of Ms*** received by Group Health Cooperative We understand Ms*** expressed concerns about not receiving her “Pass Through” funding from Group Health post for the month of JanuaryIt has been confirmed Ms***
Health Savings Account (HAS) Eligibility Worksheet was received on January 27, Pass Through funding is distributed once a month, on the 22nd. The time line was missed for the month of JanuaryOn February 22nd Ms*** will receive funding (retroactive) for January, February and March in the amount of $for each monthWe apologize for the negative experience Ms*** may have encountered. Thank you again for taking the time to bring this to our attentionIf you have any questions regarding this matter, you may reach me at ***

Complaint: ***I am rejecting this response because I refuse to pay for office visits where I did not get proper care I have health insurance and I went to their medical center and did not get the care I deserved I will not pay for the office visits I did not get care for, I will only pay for the 3rd where I finally got proper care$out of pocket to get some antibiotics for pneumonia, how is that right and fair as I have your insurance?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. It's not really to my satisfactory but I don't have the energy to fight, as I am disabled
Sincerely,
*** ***

Dear Mr***:I am writing in response to your February 8, inquiry on behalf of MsJ*** ***received by Group Health Cooperative.We understand Ms*** expresses frustration regarding her available and covered chiropracticservices.We apologize for the experience Ms*** may have
encounteredWhile we do find acoaching opportunity is appropriate for the customer service personnel Ms*** spoke with,her plan does have a limit of only chiropractic visits per calendar yearThis does not excludeher having additional services, but it does mean that additional visits are not covered by the planfor which she enrolled.A review of the billed services for chiropractic care does show claims have been received.While several of those are still pending process, the benefit will exhaust with these submittedclaims.For your convenience, her plan benefit is as follows:• Manipulative therapy of the spine and extremities when in accordance with Group Healthclinical criteria is limited to a combined total of visits per calendar year.• Under the Access PPO Gold plan she may use both preferred and non-preferred providersfor her services.• After annual deductible of $for preferred providers, services have $copay forprimary care providers (Chiropractic care is considered primary care).• Any services other than office visit, including surgical services also carry 20% plancoinsurance after deductible is satisfied.Group Health Options, Inc.Health Plan Administration*** ** *** *** *
*** ** *** TTY Relay*** Fax*** For Non-preferred providers an annual deductible of $and 50% plan coinsurance arein effect for this plan.• The plan also has Welcome visits where annual deductible does not apply for the first 5office visits per calendar year for preferred provider services.Because each employer plan may have a variety of options for these services, we would not beable to compare the features of any unknown employer coverage to those available under thisindividual and family offered plan.Thank you again for taking the time to bring this to our attentionIf you have any questionsregarding this matter, you may reach me at ***.Sincerely,Rebecca H**Health Plan Administration

I am writing in response to your August 18, inquiry from Ms*** *** on behalf of ***, and received by Kaiser Foundation Health Plan of Washington.We understand Ms*** submitted a complaint on behalf of her father *** *** regardingdisputed charges for which he received
billing statements since May 31, continuing to requestpaymentShe also shared that several attempts to correct the situation with Kaiser Permanente andPatient Financial Services did not resolve the matter.We apologize for the negative experience Mr*** and Ms*** may have encounteredrelated to these chargesWe completed a review of the outstanding balances for Mr***’saccount and made some corrective adjustmentsThose corrections resulted in a refund of $toMr*** for a payment he made on July 28, 2017, and should be received by mail in the next 10-days.A review of the billing history for the date of service April 14, (the billed amount of $532.02)determined that the billed amount to Mr*** was a result of a payment posting error when thesecondary insurance payment was applied to the accountThe secondary insurance plan paid theservice in full, but the contractual discount from the health plan was not properly re-applied with thatpaymentOur Patient Financial Services representative remedied this by posting all of thenecessary adjustments required per the explanation of benefits (EOB) from the health plan toresolve this balance.The representative was able to resolve the other past due balance for $by posting a remainderof the payment made by Mr*** on June 19, for $21.58, which was intended to pay thisbalance at the time the other charge was disputedOur process is to post payments received to theoldest active balance firstSince the April 14, date of service reflected a balance still due, priorpayments were applied accordinglyWith the corrections made to the April 14, balance, therepresentative then re-applied the patient payments to the remaining balancesThe result was a$refund, and a zero balance on Mr***’s account.We apologize for the difficulty both Mr*** and Ms*** experienced for correcting thisbalance issueTheir story was communicated to the appropriate management for coaching andimproved customer experience in the futureThank you again for taking the time to bring this to ourattentionIf you have any questions regarding this matter, you may reach me at ***.Sincerely,Rebecca H**Health Plan Administration