NCAS Inc.

August 29, Dear *** ***:*** Administrators (***) is in receipt of the request for review of a complaint Submitted by your office on 08/05/11:49:35AM - assigned ID #:***You have requested a written response within days of your notice dated 08/18/I
apologize for the late response regarding this matter and have made every attempt to comply with your request.*** Administrators is a third party administrator and we administer the benefits for the *** ** *** Health Plan in accordance with the conditions as specified in their coverageEnclosed for your reference is a copy of pages from the Summary Plan Description (SPD) pertaining directly to this particular caseThe Group provides all Participants in the Plan a copy of the SPD as a guide in making decisions regarding their health care benefits*** has reviewed all documentation on file and it has been determined that the claim denied correctly in accordance with the benefits as specified in the Plan document languageThe Plan guidelines specify that the claim and all pertinent information to process the claim must be received within the timely filing limitation which is one year from the incurred date of service, According to our records the initial claim was received on 06/11/which is past the timely filing limitation, Attached is a copy of the claim and the supporting documentation from *** *** that indicate that they did not file a claim with usI have also reviewed our customer service phone records which has no record of a call regarding this matter from the Patient until 01/24/which is also past the timely filing limitationNCAS has no record of an appeal or proof of timely filing from either the member or *** *** on file to dateAs a result of our review it has been determined that the claim processed in compliance with the Plan Documentlanguage and no further action is required by us at this timeIf the member has any further questions they may contact our customer service department at the phone number on the back of the medical cardSincerely,Pam BAppeals/ Correspondence Rep

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: ***I am rejecting this response because:I had previously submitted documentation to prove that the claim was filed multiple times to NCAS within the one year that the claim occurredI can refile these documents as necessaryRegards,*** ***

August 29, 2014
Dear [redacted]:
CareFirst Administrators (CFA) is in receipt of the request for review of a complaint submitted by your office on 08/05/2014 11:49:35AM - assigned ID #:[redacted]. You have requested a written response within 10 days of your notice dated 08/18/2014. I apologize for the late response regarding this matter and have made every attempt to comply with your request.
CareFirst Administrators is a third party administrator and we administer the benefits for the [redacted] Health Plan in accordance with the conditions as specified in their coverage. Enclosed for your reference is a copy of pages from the Summary Plan Description (SPD) pertaining directly to this particular case, The Group provides all Participants in the Plan a copy of the SPD as a guide in making decisions regarding their health care benefits.
CFA has reviewed all documentation on file and it has been determined that the claim denied correctly in accordance with the benefits as specified in the Plan document language. The Plan guidelines specify that the claim and all pertinent information to process the claim must be received within the timely filing limitation which is one year from the incurred date of service. According to our records the initial claim was received on 06/11/2014 which is past the timely filing limitation. Attached is a copy of the claim and the supporting documentation from [redacted] that indicate that they did not file a claim with us, I have also reviewed our customer service phone records which has no record of a call regarding this matter from the Patient until 01/24/2014 which is also past the timely filing limitation. NCAS has no record of an appeal or proof of timely filing from either the member or [redacted] on file to date. As a result of our review it has been determined that the claim processed in compliance with the Plan Document. language and no further action is required by us at this time. If the member has any further questions they may contact our customer service department at the phone number on the back of the medical card.
Sincerely,Pam B. Appeals/Correspondence Rep.

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:I have a copy from [redacted] of dates of attempts to contact NCAS
with no response. The filing of the claim was sent on multiple
occasions within the time frame of the one year. However, NCAS failed to
respond. This claim should therefore be paid by NCAS to the provider. 
Regards,
[redacted]

Review: I am from [redacted], MD and had a medical issue and went to [redacted] on 1/12/13. I gave them all of my necessary insurance information (which I was covered), thinking I would have ease of getting care since I was traveling in PA. I did received great care there. However, I received a "No Insurance Company Response" letter a few months later (March) after which I proceeded to contact them. During this call, ** verified the correct insurance information and said they would refile the claim. This same song and dance went on multiple times with them sending me "No Ins Co Response" letters, me calling them, ** saying they would refile and verifying the insurance. I had even contacted NCAS who said they never received any claims. Time went on and ** starting sending me late fees for this claim not being paid. I called and explained and they removed the late fees from the 9/2013-1/2014. I had been fed up for a time having to call and explain my situation. However, the worst was when I called in June 2014 and ** told me that they do not file to NCAS and I would have to do it on my own! No one had ever told me this until almost a year and a half later. I had ** send me the claim and I filed it directly with NCAS. Of course it was denied by NCAS since it fell outside of the 1 year claim filing window. In August 2014, I again called my insurance company (NCAS), who said the first claim they had ever seen was from me in June and it wouldn't be covered but I could send a letter to appeals. I also called ** and again explained to them my entire situation. The gentleman there (Antonio) was very pleasant. However, when I asked him where he sent the claims and if they did not receive a claim who did they call. He explained that ** does not call insurance companies or patients. Isn't that their job? Antonio also told me that they would be happy to file a "Proof of Timely Response" letter to NCAS. How can I believe that they are trying to help me when they haven't in the past? I asked him to file this form with my insurance company and also send me a copy directly (so that I could also file it). This whole situation has been extremely unethical with ** blaming NCAS and NCAS blaming **. I do not know who to trust. I have played the middle man for the past year and a half and gotten nowhere. I will probably never go to a [redacted] again and thankfully my employer has a new insurance provider!Desired Settlement: To have the $206 cleared from my name.

Business

Response:

August 29, 2014Dear [redacted] Administrators ([redacted]) is in receipt of the request for review of a complaint Submitted by your office on 08/05/2014 11:49:35AM - assigned ID #:[redacted]. You have requested a written response within 10 days of your notice dated 08/18/2014. I apologize for the late response regarding this matter and have made every attempt to comply with your request.[redacted] Administrators is a third party administrator and we administer the benefits for the [redacted] Health Plan in accordance with the conditions as specified in their coverage. Enclosed for your reference is a copy of pages from the Summary Plan Description (SPD) pertaining directly to this particular case. The Group provides all Participants in the Plan a copy of the SPD as a guide in making decisions regarding their health care benefits.[redacted] has reviewed all documentation on file and it has been determined that the claim denied correctly in accordance with the benefits as specified in the Plan document language. The Plan guidelines specify that the claim and all pertinent information to process the claim must be received within the timely filing limitation which is one year from the incurred date of service, According to our records the initial claim was received on 06/11/2014 which is past the timely filing limitation, Attached is a copy of the claim and the supporting documentation from [redacted] that indicate that they did not file a claim with us. I have also reviewed our customer service phone records which has no record of a call regarding this matter from the Patient until 01/24/2014 which is also past the timely filing limitation. NCAS has no record of an appeal or proof of timely filing from either the member or [redacted] on file to date. As a result of our review it has been determined that the claim processed in compliance with the Plan Document. language and no further action is required by us at this time. If the member has any further questions they may contact our customer service department at the phone number on the back of the medical card.Sincerely,Pam B. Appeals/ Correspondence Rep.

Consumer

Response:

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]

Review: [redacted]

I am rejecting this response because:

I have a copy from [redacted] of dates of attempts to contact NCAS

with no response. The filing of the claim was sent on multiple

occasions within the time frame of the one year. However, NCAS failed to

respond. This claim should therefore be paid by NCAS to the provider.

Regards,

Business

Response:

August 29, 2014Dear [redacted]:CareFirst Administrators (CFA) is in receipt of the request for review of a complaint submitted by your office on 08/05/2014 11:49:35AM - assigned ID #:[redacted]. You have requested a written response within 10 days of your notice dated 08/18/2014. I apologize for the late response regarding this matter and have made every attempt to comply with your request.CareFirst Administrators is a third party administrator and we administer the benefits for the [redacted] Health Plan in accordance with the conditions as specified in their coverage. Enclosed for your reference is a copy of pages from the Summary Plan Description (SPD) pertaining directly to this particular case, The Group provides all Participants in the Plan a copy of the SPD as a guide in making decisions regarding their health care benefits.CFA has reviewed all documentation on file and it has been determined that the claim denied correctly in accordance with the benefits as specified in the Plan document language. The Plan guidelines specify that the claim and all pertinent information to process the claim must be received within the timely filing limitation which is one year from the incurred date of service. According to our records the initial claim was received on 06/11/2014 which is past the timely filing limitation. Attached is a copy of the claim and the supporting documentation from [redacted] that indicate that they did not file a claim with us, I have also reviewed our customer service phone records which has no record of a call regarding this matter from the Patient until 01/24/2014 which is also past the timely filing limitation. NCAS has no record of an appeal or proof of timely filing from either the member or [redacted] on file to date. As a result of our review it has been determined that the claim processed in compliance with the Plan Document. language and no further action is required by us at this time. If the member has any further questions they may contact our customer service department at the phone number on the back of the medical card.Sincerely,Pam B. Appeals/Correspondence Rep.

Consumer

Response:

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved] Review: [redacted]I am rejecting this response because:I had previously submitted documentation to prove that the claim was filed multiple times to NCAS within the one year that the claim occurred. I can refile these documents as necessary. Regards,[redacted]