Lone Star Siding Solutions

Dear Ms***:This is in response to the grievance we received on June 22, 2015, regarding premium duesYou are requesting we refund $4,300.00, in premium dues for the year 2014, or we apply the funds to your health coverage for 2015, as you feel you were unable to access care.Your request has been denied for the following reasons: * During the course of our review it was noted that you are enrolled in the Ultimate PPO plan through Covered California (CCA) effective March 1, The benefits of your health plan are outlined in the Evidence of Coverage (EOC). * According to your EOC your monthly premiums are as stated in your appendix and are set for a rating period that runs for the calendar yearThere are no provisions in your health plan that allows for Blue Shield to waive your premium dues. * Our records show we received ten premium payments totaling $3,756.40, for medical and nine premium payments totaling $506.70, for dentalWith a combined total of $4623.10, from March 2014, thorough December All premium payments were applied to the account correctly. * Based on research our records show you were fully eligible with access to care benefitsWe were unable to find any errors on your account supporting your requestTherefore we are unable to refund or credit your premium dues at this time. * If you would like to further pursue a refund or have questions regarding eligibility please contact CCA directly at ***, for additional assistance.Although we understand your reasons for your request, we are unable to comply with your request due to provisions of your EOCTherefore we must be consistent with the agreement terms of your plan so that we are fair and equitable to all subscribers.Your request was reviewed by a grievance coordinator who is knowledgeable about your plan's benefits and coverageWe have enclosed copies of the appropriate pages of the EOC for your health plan and underlined the language that supports our decision.You have the right to request an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC)If your appeal meets the criteria as determined by the DMHC, an independent review organization as selected by the DMHC will review the pertinent issue(s) and/or medical documentationWe have enclosed an IMR Application Form and addressed envelope for your convenienceIf you choose to pursue an IMR, please forward your request to the DMHC directly.You are entitled to, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits.If you have questions about this letter, please contact me directly. Sincerely,*** *Coordinator

I aFirst, I would like to thankthe Revdex.com for a quick forwarding of Blue Shield correspondence. And the correspondence again makes meconfused. I do not understand when BlueShield of California said that I have not completed the grievance process. If there will be more steps to comply, why Mr.SGof Medicare Appeals & Grievances, on behalf of Blue Shield Plus, acknowledged that "theclaim was initially processed incorrectly and the claim to bereprocessed correctly and payment has been recently issued according to planbenefits". I do not think BlueShield would issue the refund check unlessit had all required papersMoreover, the Section concerning Hearingservices of the Blue Shield Plus handbook wrote "Simply submityour bill to Claim Department". Asmentioned in my December 28, 2014, I had followed all requisiteinstructions. Please review allcorrespondence between me and MrSGof Medicare Appeals & GrievancesDepartment of Woodland Hills, CA Ibelieve I had completely fulfilled mypart.Then yesterday, April 27,2015, I received a letter dated 4/20/from Blue Shield of California, P.O.Box 272640, Chico, CA95927-The letter wrote: "A stop payment hasbeen placed on the payment below as of 4/21/and if you receive thispayment after that date, please do not try to cash itOur records reflect thefollowing information about payment of this claim: Claim Number: *** Amount: $1,000.00 Payment Number: *** Payment Date: January27, 2015 Paid To: To** ** Summary Payment: $1,009.76The reason for a stop paymentwas because you have not received this check to date".Although I have not receivethe payment, the letter above is a proofindicating that all required papers had been obtained. It is hard, however, to beconvinced for me that the check had been either lost or misplaced during thedelivery as I never miss correspondence from Blue Shield for nearly yearsboth at work and at retirementm rejecting this response because:

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield)However, based on the information provided we are unable to identify Ms*** as a Blue Shield of California memberTherefore, we are unable to proceed with an investigation of Ms***’s concerns at this
time

Dear Revdex.com, This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on February 2, 2016, concerning a Blue Shield enrollee by the name of *** ***The information provided by the Revdex.com included a consumer complaint
against Blue ShieldWe thank you for forwarding these concerns to Blue Shield for review and would like to inform you that *** ***, has not completed the grievance process with the planWe are initiating a grievance to address the concerns raised in the correspondence submittedPlease be advised that, grievance are resolved within days of the receipt dateA response to the review will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.comIf you have additional questions regarding this matter, please contact me directly at the telephone number listed belowSincerely, *** *** *** *** ***

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield)In order to research and properly respond to the member's concerns, we ask that you provide the subscriber identification number of the account in question

Revdex.com:
I have reviewed the response made by the business in reference to my concern, and find that this resolution is satisfactory to me. As long as I am refunded the amount illegally charged to my credit card on 2/1/by Blue Shield. This is a billing error on Blue Shield's part, why does it take so long for them to refund their employee's mistake?

I am rejecting this response because: -No specifics are provided but a generic response It seems our complaint is completely ignored as was our appeal before .- Why surgeon is paid but not hospital Which policy or coverage states that .- Surgeon has justified reason for surgery to insurance and was paid ( we have copy of Surgeon's response to insurance )- Surgeon has to do surgery at some hospital , so on what basis payment can be denied to hospital by insurance.- Blue Shield need to conduct internal inquiry for above to justify non payment to hospital / payment to surgeon with an immediate response to end more torture and stress to patient

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield)Our records indicate the member’s eligibility has been previously corrected as requested, however, we would like to inform you that we have initiated a grievance analysis to review and respond to the concerns
raised in the correspondence submittedWe will provide a written response to *** *** within calendar daysWe have mailed an acknowledgement letter to Mr***’s mailing address with additional information regarding the grievance process as well as direct contact information for her assigned grievance coordinatorThank you

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield)We would like to inform you that we have initiated a grievance analysis to review and respond to the concerns raised in the correspondence submittedWe will provide a written response to ***
*** within calendar daysWe have mailed an acknowledgement letter to Mr***’s mailing address with additional information regarding the grievance process as well as direct contact information for her assigned grievance coordinatorThank you

Re Case: *** Dear Revdex.com: This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on June 22, 2015, concerning a Blue Shield enrollee by the name of *** ***The information provided by the Revdex.com
included a consumer complaint against Blue Shield. We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submittedA response will be sent directly to *** ***Our records do not reflect that a signed release of information was submitted with the correspondence signed by the Revdex.comUnfortunately, without a signed release of information from *** ***, we are unable to provide a copy of the resolution to the Revdex.comIf *** *** has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at *** or mail at:P.OBox 5588El Dorado Hills, CA, 95762 If you have any additional questions regarding this matter, please contact me directly at the telephone number listed below. Sincerely,*** ***, Executive Inquiry Coordinator

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on September 8, 2015, concerning a Blue Shield enrollee by the name of *** *** *** (Ms***)The information provided by the Revdex.com included a consumer complaint
against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that Ms***, has completed our grievance process regarding this specific issueA response letter was mailed directly to the member on August 27, If the member is dissatisfied with the grievance resolution, she may contact the Department of Managed Health Care for additional assistanceThe department has a toll-free telephone number (1-88-688-9891) for the hearing and speech impairedThe department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,*** ***, Executive Inquiries CoordinatorGrievance Department(916) 350-

Dear Ms***,This is in response to the grievance we received on June 4, 2015, regarding billing discrepancies on your accountYou are requesting Blue Shield of California (Blue Shield) update your billing account to correct any errors, and to provide you with two months of coverage credit on your account. Your request has been partially approved for the following reasons:During the course of our review it was noted that you are enrolled in the Blue Shield Silver PPO plan, with an original effective date of March 1, An Evidence of Coverage (EOC), containing the terms and conditions of your plan is sent to you once after enrollment, and again upon each renewal.We have approved your request to correct any billing errors associated with your account, which may have caused your providers to be incorrectly advised of your eligibility status at the time of their inquiry to Blue Shield.Your request for two months of coverage credit to be applied to your account has been denied because although you have experienced issues on your account, there are several claims in various months that have been processed and paid.While we understand the reason for your request for two months of coverage credited to your account, we have denied this request because you have claims paid throughout Your account has been corrected, and you are currently showing a credit on your account in the amount of $93.86.Blue Shield would like to apologize to you and your providers for any inconvenience you may have experienced while covered through our companyWe are making many changes within the company to adapt to the frequent changes occurring in the industryWe will take your experience into account when we are making decisions which will affect our members now, and in the future to ensure that our service to you is the best it can be.Your request was reviewed by a grievance coordinator who is knowledgeable about your plan's benefits and coverageWe have enclosed copies of the appropriate pages of the Evidence of Coverage (EOC) for your health planIn addition, we have underlined the language that supports our decision.You have the right to request an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC)If you appeal meets the criteria as determined by the DMHC, an independent review organization as selected by the DMHC will review the pertinent issue(s) and/or medical documentationWe have enclosed an IMR Application Form and addressed envelope for your convenienceIf you choose to pursue an IMR, please forward your request to the DMHC directly.You are entitled to, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits.If you would like more information about the diagnosis and treatment codes and their meanings, used in making this decision, please contact your provider.If you have questions about this letter, please contact me directly.Sincerely, *** **, CoordinatorGrievance Department###-###-####

I am rejecting this response because: As the letter from Blue Shield indicates, I have indeed gone through the entire second level grievance process with Blue Shield and I have STILL yet to have my issue resolvedI have left additional voicemails and emails with my initial grievance officer and I have also left voicemails with the officer that was in contact with the rep from the Dept of Managed Health careIn all cases, I have requested a call back so that I can know the remaining balance I need to pay to resolve this issue and to pay it, and yet I have still not been able to speak to anyone in order to do thisIn my second level grievance, I had requested that the months in which the grievance officer failed to return any of my dozens of calls have the premium for those months paid waived, but they declined my requestTherefore, since I received a written letter from Blue Shield grievances asking me to call them directly (which I did, twice a week for weeks +) I have been without health care since at least October through the end of the year.It's beyond unacceptable that I can't resolve this issue even if I wanted to because they've made it impossible for me to reach a grievance officer with the correct information regarding my case and to resolve itInstead, I have to accept no health coverage during all these months and then I have to pay the full premium for those same months that they refused to call me back

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on April 24, 2015, concerning a Blue Shield enrollee by the name of ** **The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for
forwarding these concerns to Blue Shield for review and would like to inform you that ** **, has not completed the grievance process with the planWe are initiating a grievance to address the concerns raised in the correspondence submittedPlease be advised that, grievances are resolved within days of the receipt dateA response to the review will be sent directly to ** **, and a copy of the resolution letter will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.com.If you have any additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,*** **, Executive Inquiries CoordinatorGrievance Department###-###-####

I am rejecting this response because: Per my conversation with Michela Lin grievances, grievances has found on 4/7/that my complaint from January is still accurate and that I am still due a reimbursement. Also, I was informed that my reimbursement was requested to be expedited since Blue Shield erroneously deducted the wrong amount from my checking account. Since this current form of the letter sent from Blue Shield doesn't in any way reflect that conversation I cannot accept it as a reply to my issue and I do not agree that I should have to go through a further grievances process of additional days. Thank you

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on July 20, 2015, concerning a Blue Shield) on July 20, 2015, concerning a Blue Shield enrollee by the name of *** ***The information provided by the Revdex.com included a
consumer complaint against Blue Shield. We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submittedA response will be sent directly to *** ***Our records do not reflect that a signed release of information was submitted with the correspondence sent by the Revdex.comUnfortunately, without a signed release of information from *** ***, we are unable to provide a copy of the resolution to the Revdex.comIf *** *** has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at *** or by mail at: *** *** *** El Dorado Hills, CA 95762If you have any additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely, *** ***Executive Inquiry Coordinator*** ***

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield) for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submittedA response will be sent directly to *** ** within calendar daysOur records do not
reflect that a signed release of information was submitted with the correspondence sent by the Revdex.comUnfortunately, without a signed release of information from *** **, we are unable to provide a copy of the resolution to the Revdex.com

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on February 2, 2016, concerning a Blue Shield enrollee by the name of *** ***The information provided by the Revdex.com included a consumer complaint against Blue
Shield. We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submittedA response will be sent directly to *** ***Our records do not reflect that a signed release of information was submitted with the correspondence sent by the Revdex.comUnfortunately, without a signed release of information from *** ***, we are unable to provide a copy of the resolution to the Revdex.comIf *** ***, has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at 916-350-7405 or by mail at: *** *** ***
** *** *** ** *** If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,*** ***, Executive Inquiry Coordinator

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on May 1,2015, concerning a Blue Shield enrollee by the name of *** ***The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you
for forwarding these concerns to Blue Shield for review and would like to inform you that *** ***, has not completed the grievance process with the planWe are initiating a grievance to address the concerns raised in the correspondence submittedPlease be advised that, grievances are resolved within days of the receipt dateA response to the review will be sent directly to *** ***, and a copy of the resolution letter will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.com.If you have additional questions regarding this matter, please contact me directly at the telephone number listed below

We thank you for forwarding these concerns to Blue Shield of California (Blue Shield) for review and would like to inform you that we are currently reviewing the concerns raised in the complaint submittedWe will conduct an audit of the processing of the claims in question and will contact Ms
*** *** shortly with our determination