Initial Business Response / [redacted] (1000, 5, 2014/09/25) */ Our records indicate that the complainant did contact our office regarding a concern pertaining to the coverage of her pharmacy claims and that she was referred to a Customer Service Manager The Customer Service Manager contacted the complainant's pharmacy and it was discovered that the pharmacy was submitting the claims(s) in question to the incorrect Pharmacy Benefit Manager (PBM), which was resulting in the claim denialsThe Customer Service Manager worked with the pharmacy to re-submit the claim in question to the correct PBM and the claim processed successfully as a result The Customer Service Manager then contacted the complainant directly, provided this information and addressed her concernsWe understand that the complainant was satisfiedAs was communicated to the complainant at that time, if she experiences any additional issues with the filing of her pharmacy claims, she is welcome to contact the Customer Service Manager directly for assistance
Initial Business Response / [redacted] (1000, 5, 2016/01/13) */ Our office has received an inquiry regarding this matter directly from the ComplainantWe have responded to the Complainant in writingIf the Complainant has any further questions, he may contact PreferredOne's Customer Service Department at [redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case Initial Consumer Rebuttal / [redacted] (2000, 7, 2016/01/14) */ (The consumer indicated he/she ACCEPTED the response from the business.) Thesituation has been resolved
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me
PreferredOne has again spoke with member and went over the appeal rights and also sent an appeal formMember also requested the relevant information that was used to make the initial determination which will be sent to the member
Initial Business Response / [redacted] (1000, 5, 2016/02/24) */ Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release information regarding the claims in question without a signed HIPAA authorization from the member However, our office has issued a written response to this complaint directly to our memberIn addition to addressing their concerns, this response also included notice of their applicable appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted] Initial Consumer Rebuttal / [redacted] (3000, 7, 2016/02/26) */ (The consumer indicated he/she DID NOT accept the response from the business.) We have received the response from Preferred One by mail today, February After a critical review of their response, we believe we have solid grounds to make a written appeal soonest, consistent with our rights specified on the letterwe will communicate directly with them in complete fairness and good faithWe will provide other documentation in our direct response to them to support our case, including, but not limited to, earlier visits in the same year at Allina Health which we have discovered and realized just now, were also not coveredThank you Final Consumer Response / [redacted] (3000, 11, 2016/02/29) */ (The consumer indicated he/she DID NOT accept the response from the business.) Our response is only to physically acknowledge receipt of the letter dated February and this is very clearWE NEVER SAID THAT WE HAVE ACCEPTED THEIR INITIAL RESPONSE - THAT IS AN ENTIRELY DIFFERENT STORY AND PLEASE DO NOT TRY TO TWIST IT! WHAT WE SAID IS THAT WE WILL APPEAL THEIR DECISION TO DENY THE CLAIM AND WILL COMMUNICATE DIRECTLY WITH THEMAGAIN THIS IS NOT THE SAME AS ACCEPTING THEIR RESPONSETHE APPEAL IS A FORM OF REBUTTAL IF YOU LIKE TO PUT IT THAT WAY Final Business Response / [redacted] (4000, 14, 2016/03/01) */ PreferredOne believes that it has appropriately responded to this consumers complaint to the extent possible at this time As previously communicated, PreferredOne has issued the consumer a direct response to their concerns and has provided them with appropriate direction and instruction regarding their right to address any further coverage concerns by initiating an appeal directly with our officeThe consumer has acknowledged that they have received our response, has indicated that they agree to continue to address their coverage concerns with us directly and has stated that they are preparing to file an appeal with our officeOnce that appeal has been received by our office, we will review the information presented and will respond to the consumer directly in accordance with their Plans appeal provisions Again, if the consumer has any additional questions or concerns in the meantime, they are welcome to contact PreferredOne's Customer Service Department at [redacted] or [redacted]
Initial Business Response / [redacted] (1000, 6, 2014/10/02) */ We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information This consumer purchased a contract for a plan of individual health care benefits from PreferredOne Insurance Company ("PIC"), which became effective on January 1, In January of 2014, PIC began receiving medical claims and information that indicated the presence of a condition that may have resulted from an accident or injuryAs a result, information was requested from the consumer in order to ascertain whether their medical condition was the result of an accident or injury in which another insurer may be involved so that PIC could appropriately coordinate benefits under the terms of the individual contractThe consumer responded, stating that their condition resulted from a work related injury; therefore, in accordance with the terms of the individual contract, as these medical claims qualify for primary coverage under workers compensation, the claims were denied as a work related injury and an Explanation of Benefits statement was issued to the consumer notifying them of this determination As the consumer has indicated in their complaint to your office, they have since provided their workers compensation insurance information to their medical providers so that these claims can be filed for consideration under that primary policyOnce the workers compensation carrier makes a determination on those claims, those determinations may then be submitted to PIC for reconsideration and coordination of benefits PIC then began receiving medical claims for another condition and requested information from the consumer in order to ascertain whether this condition was also a result of an accident or their work related injuryIn response, the consumer contacted our office and indicated that it was not, however, information that was provided to PIC by the consumer's physicians office indicated that this condition could be related to the work related injuryAs a result, the claims for this condition were denied as a work related injury The consumer recently contacted our office regarding this determinationBased on the information provided by the consumer, our customer service representative advised the consumer that they would have these claims reviewed and would follwith the consumerUpon review of the file, the claims and the information provided by the consumer, it was determined that this condition was not related to the work related injury and the claims for this condition were adjustedOur customer service representative attempted to contact the consumer to advise them of this, however, the telephone number provided was not answered and there was no voicemail on which to leave a message On October 1, our office mailed the consumer a written response to this complaint, which includes information regarding our findings, the outcome of our review and notice of the recent claim adjustmentsFollowing the claim adjustments, the consumer was also issued Explanation of Benefit statements that reflect the payment made on the adjusted claims If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at [redacted] or toll free at [redacted]
Initial Business Response /* (1000, 5, 2016/01/13) */
Our office has received an appeal regarding this matter directly from the ComplainantWe have notified the Complainant in writing that their appeal has been received and is being processed according to their Plans Appeal ProceduresAs
indicated in that letter, our office will issue the Complainant a written response to the appeal once the appeal review is completeIf the Complainant has any questions in the meantime, they may contact PreferredOne's Customer Service Department at *** or *** and request to speak with the Grievance Specialist assigned to her case
Initial Business Response /* (1000, 5, 2014/11/05) */
We are unable to identify this complainant with the information that they provided in their complaintPlease provide the full name of the covered member and their PreferredOne Subscriber ID # so that we may research and respond to this
complaintThank you
Initial Consumer Rebuttal /* (3000, 7, 2014/11/06) */
(The consumer indicated he/she DID NOT accept the response from the business.)
According to the Revdex.com guidelines, I am directed against providing personal identifiable informationThe response from PreferredOne has requested personal identifiable information that is not required based on the nature of my complaint (that searching for service providers without logging in with an ID provides provider information even when account sub category is properly identified)
Final Business Response /* (4000, 9, 2014/11/11) */
We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information
PreferredOne Insurance Company ("PIC") offers various provider network options to our membersMembers do have the ability to search our provider network by either logging into their account by providing their member ID number or not providing their member ID number on our websiteHowever, if a member does not log into their account by providing their member ID number, the standard provider directory is displayed with the following disclaimer at the top of the provider search"PreferredOne has made this standard provider directory accessible by hand held devicesYour plan's network may differReview your plan documents for a more accurate listing."
If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at XXX-XXX-XXXX or toll free at X-XXX-XXX-XXXX
Final Consumer Response /* (3000, 11, 2014/11/12) */
(The consumer indicated he/she DID NOT accept the response from the business.)
We were using a personal computer and not a hand held device to search your listing
The number one listing after typing in our "Select" membership type and our zip code was a healthcare provider that is not covered under the "Select" type plan, only other plansIt is therefore our conclusion that your website is providing inaccurate information in order to avoid paying for claims
After discussing this issue with your customer service department, they repeated that their website will not show accurate information unless a client logs in using member ID and using a computer or laptop (mobile devices are known not to work)As we were using a personal computer that was not secure, we were not able to log in with an ID and therefore used the identifying membership type and zip code located on our membership card provided by PreferredOneThe result of this search was a list of service providers in our area that were listed as In-Networkweeks after receiving care from the in-network provider, we were told that they were actually out of network and are required to pay $The customer service representative stated that there was nothing they could do to fix this problem as it was human error on our behalf - when in reality it is a website error that PreferredOne will openly admit in customer service calls
Initial Business Response /* (1000, 5, 2016/03/09) */
Our office has notified this member of the coverage limitations and exclusions of their PlanOur office has also advised the member of their appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer
Service Department at *** or ***
Initial Consumer Rebuttal /* (3000, 7, 2016/03/09) */
(The consumer indicated he/she DID NOT accept the response from the business.)
I,Terry, was fully covered when this accident occurredIt was a simple emergency room visit involving stitching a long deep gash on my arm and stopping blood flowAt no point in time did I receive any correspondence from Preferred one concerning this ER nessessityThe only notice we received was a call from the ERROR that the bill was past dueAt that time my wife called Preferred one and was told that bill was "in system"Received call some time later from ER again saying they had resubmitted the bill to preferred one and still no paymentCalled preferred one again and man spoke with said yes it had been resubmitted actually another two times but unfortunately by then it was over time limitMan on phone from preferred one was informed that if it was over limit it was their inactivity and my wife asked to be transferred to a supervisorWife was informed that supervisor was unavailableWife asked for a call back from supervisorNone cameWife called back days in a row and "supervisor " was never "available"We have been told that preferred one is bad about ducking paymentsI am a manager for ABC Group and will be notifying corporate again concerning this non paymentIf need be we will also after all this point in time consult/hire an attorneyThis is insane and poor business practice how preferred one has mishandled this simple emergency room coverage
Final Business Response /* (4000, 9, 2016/03/11) */
At the time the services were rendered, PreferredOne Administrative Services was the third party administrator ("TPA") for the complainant's employer and provided administrative services with respect to their Plan until November 30, Our office has issued a written response directly to this complainant advising him to contact the Plan Sponsor and have also provided him with the name and phone number of the Plan Sponsor
Due to HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable to release information regarding the issue question without a signed HIPAA authorization from the member However, our office has contacted the member to discuss this matter and we
did advise the member of their appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer Service Department at ###-###-#### or ###-###-####
Our office has responded to an appeal regarding this matter directly from the ComplainantWe have notified the Complainant in writing of the decision regarding the appealIf the Complainant has any questions, they may contact PreferredOne's Customer Service Department at ###-###-#### or
###-###-#### and request to speak with the Grievance Specialist assigned to their appeal
Initial Business Response /* (1000, 5, 2016/01/13) */
Our office has received an inquiry regarding this matter directly from the Complainant. We have responded to the Complainant in writing. If the Complainant has any further questions, he may contact PreferredOne's Customer Service Department at...
[redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case.
Initial Consumer Rebuttal /* (2000, 7, 2016/01/14) */
(The consumer indicated he/she ACCEPTED the response from the business.)
The3 situation has been resolved.
The member/patient in this case is someone other than the party that has filed this complaint. Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release the patients protected health information. However, we can confirm that...
our office has been in direct contact with the member/patient and we have satisfactorily resolved their claim issue. If the member/patient has any additional questions about their claim, they may contact PreferredOne's Customer Service Department at ###-###-#### or ###-###-####. With regard to the complainants request for reimbursement of premiums paid, please be advised that the complainant is enrolled in a “self-insured” benefit plan that is sponsored and maintained by their employer (Plan Sponsor). This means that the Plan Sponsor (employer) collects and maintains their plans premiums and pays eligible medical claims from its own assets. While the Plan Sponsor (employer) contracted with PreferredOne to provide claim processing, pre-certification and other administrative services for their plan from January 1 - December 31, 2017, this did not include the collection of, or PreferredOne’s receipt of, their eligible employees medical premiums. Therefore, if the complainant has any outstanding concerns pertaining to their premium payments, they will need to address those concerns with their employer directly.
Initial Business Response /* (1000, 5, 2016/02/02) */
Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable to respond directly to you regarding the claim in question without a signed HIPAA authorization from the member.
However, our...
office has contacted the member to discuss this matter and we did advise the member of their appeal rights and we provided them with an Appeal Form to facilitate their filing of an appeal. If the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Initial Business Response /* (1000, 5, 2016/02/24) */
Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release information regarding the claims in question without a signed HIPAA authorization from the member.
However, our office...
has issued a written response to this complaint directly to our member. In addition to addressing their concerns, this response also included notice of their applicable appeal rights. If the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Initial Consumer Rebuttal /* (3000, 7, 2016/02/26) */
(The consumer indicated he/she DID NOT accept the response from the business.)
We have received the response from Preferred One by mail today, February 26 2016. After a critical review of their response, we believe we have solid grounds to make a written appeal soonest, consistent with our rights specified on the letter. we will communicate directly with them in complete fairness and good faith. We will provide other documentation in our direct response to them to support our case, including, but not limited to, earlier visits in the same year at Allina Health which we have discovered and realized just now, were also not covered. Thank you.
Final Consumer Response /* (3000, 11, 2016/02/29) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Our response is only to physically acknowledge receipt of the letter dated February 23 2014 and this is very clear. WE NEVER SAID THAT WE HAVE ACCEPTED THEIR INITIAL RESPONSE - THAT IS AN ENTIRELY DIFFERENT STORY AND PLEASE DO NOT TRY TO TWIST IT! WHAT WE SAID IS THAT WE WILL APPEAL THEIR DECISION TO DENY THE CLAIM AND WILL COMMUNICATE DIRECTLY WITH THEM. AGAIN THIS IS NOT THE SAME AS ACCEPTING THEIR RESPONSE. THE APPEAL IS A FORM OF REBUTTAL IF YOU LIKE TO PUT IT THAT WAY.
Final Business Response /* (4000, 14, 2016/03/01) */
PreferredOne believes that it has appropriately responded to this consumers complaint to the extent possible at this time.
As previously communicated, PreferredOne has issued the consumer a direct response to their concerns and has provided them with appropriate direction and instruction regarding their right to address any further coverage concerns by initiating an appeal directly with our office. The consumer has acknowledged that they have received our response, has indicated that they agree to continue to address their coverage concerns with us directly and has stated that they are preparing to file an appeal with our office. Once that appeal has been received by our office, we will review the information presented and will respond to the consumer directly in accordance with their Plans appeal provisions.
Again, if the consumer has any additional questions or concerns in the meantime, they are welcome to contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.
Initial Business Response /* (1000, 5, 2014/09/25) */
Our records indicate that the complainant did contact our office regarding a concern pertaining to the coverage of her pharmacy claims and that she was referred to a Customer Service Manager.
The Customer Service Manager contacted the...
complainant's pharmacy and it was discovered that the pharmacy was submitting the claims(s) in question to the incorrect Pharmacy Benefit Manager (PBM), which was resulting in the claim denials. The Customer Service Manager worked with the pharmacy to re-submit the claim in question to the correct PBM and the claim processed successfully as a result.
The Customer Service Manager then contacted the complainant directly, provided this information and addressed her concerns. We understand that the complainant was satisfied. As was communicated to the complainant at that time, if she experiences any additional issues with the filing of her pharmacy claims, she is welcome to contact the Customer Service Manager directly for assistance.
Initial Business Response /* (1000, 5, 2014/11/26) */
Our office has received an appeal regarding this matter directly from the Complainant. We have notified the Complainant in writing that his appeal has been received and is being processed according to his Plans Appeal Procedures. As indicated in...
that letter, our office will issue the Complainant a written response to his appeal once the appeal review is complete. If the Complainant has any questions in the meantime, he may contact PreferredOne's Customer Service Department at [redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case.
Initial Consumer Rebuttal /* (3000, 7, 2014/12/09) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Because the business is taking to long to resolve this issue and in the meantime the Hospital is sending me notifications that my account is going to be reported to the credit bureau and place under delinquency.
Final Business Response /* (4000, 9, 2014/12/10) */
PreferredOne mailed our response to this consumers appeal on 12/4/14. If this consumer has any further questions on this issue, he should call PreferredOne directly.
Initial Business Response / [redacted] (1000, 5, 2014/09/25) */ Our records indicate that the complainant did contact our office regarding a concern pertaining to the coverage of her pharmacy claims and that she was referred to a Customer Service Manager The Customer Service Manager contacted the complainant's pharmacy and it was discovered that the pharmacy was submitting the claims(s) in question to the incorrect Pharmacy Benefit Manager (PBM), which was resulting in the claim denialsThe Customer Service Manager worked with the pharmacy to re-submit the claim in question to the correct PBM and the claim processed successfully as a result The Customer Service Manager then contacted the complainant directly, provided this information and addressed her concernsWe understand that the complainant was satisfiedAs was communicated to the complainant at that time, if she experiences any additional issues with the filing of her pharmacy claims, she is welcome to contact the Customer Service Manager directly for assistance
I am rejecting this response because :I haven't received the information we discussed yetOnce I get what I requested I will accept
Initial Business Response / [redacted] (1000, 5, 2016/01/13) */ Our office has received an inquiry regarding this matter directly from the ComplainantWe have responded to the Complainant in writingIf the Complainant has any further questions, he may contact PreferredOne's Customer Service Department at [redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case Initial Consumer Rebuttal / [redacted] (2000, 7, 2016/01/14) */ (The consumer indicated he/she ACCEPTED the response from the business.) Thesituation has been resolved
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me
PreferredOne has again spoke with member and went over the appeal rights and also sent an appeal formMember also requested the relevant information that was used to make the initial determination which will be sent to the member
Initial Business Response / [redacted] (1000, 5, 2016/02/24) */ Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release information regarding the claims in question without a signed HIPAA authorization from the member However, our office has issued a written response to this complaint directly to our memberIn addition to addressing their concerns, this response also included notice of their applicable appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted] Initial Consumer Rebuttal / [redacted] (3000, 7, 2016/02/26) */ (The consumer indicated he/she DID NOT accept the response from the business.) We have received the response from Preferred One by mail today, February After a critical review of their response, we believe we have solid grounds to make a written appeal soonest, consistent with our rights specified on the letterwe will communicate directly with them in complete fairness and good faithWe will provide other documentation in our direct response to them to support our case, including, but not limited to, earlier visits in the same year at Allina Health which we have discovered and realized just now, were also not coveredThank you Final Consumer Response / [redacted] (3000, 11, 2016/02/29) */ (The consumer indicated he/she DID NOT accept the response from the business.) Our response is only to physically acknowledge receipt of the letter dated February and this is very clearWE NEVER SAID THAT WE HAVE ACCEPTED THEIR INITIAL RESPONSE - THAT IS AN ENTIRELY DIFFERENT STORY AND PLEASE DO NOT TRY TO TWIST IT! WHAT WE SAID IS THAT WE WILL APPEAL THEIR DECISION TO DENY THE CLAIM AND WILL COMMUNICATE DIRECTLY WITH THEMAGAIN THIS IS NOT THE SAME AS ACCEPTING THEIR RESPONSETHE APPEAL IS A FORM OF REBUTTAL IF YOU LIKE TO PUT IT THAT WAY Final Business Response / [redacted] (4000, 14, 2016/03/01) */ PreferredOne believes that it has appropriately responded to this consumers complaint to the extent possible at this time As previously communicated, PreferredOne has issued the consumer a direct response to their concerns and has provided them with appropriate direction and instruction regarding their right to address any further coverage concerns by initiating an appeal directly with our officeThe consumer has acknowledged that they have received our response, has indicated that they agree to continue to address their coverage concerns with us directly and has stated that they are preparing to file an appeal with our officeOnce that appeal has been received by our office, we will review the information presented and will respond to the consumer directly in accordance with their Plans appeal provisions Again, if the consumer has any additional questions or concerns in the meantime, they are welcome to contact PreferredOne's Customer Service Department at [redacted] or [redacted]
Initial Business Response / [redacted] (1000, 6, 2014/10/02) */ We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information This consumer purchased a contract for a plan of individual health care benefits from PreferredOne Insurance Company ("PIC"), which became effective on January 1, In January of 2014, PIC began receiving medical claims and information that indicated the presence of a condition that may have resulted from an accident or injuryAs a result, information was requested from the consumer in order to ascertain whether their medical condition was the result of an accident or injury in which another insurer may be involved so that PIC could appropriately coordinate benefits under the terms of the individual contractThe consumer responded, stating that their condition resulted from a work related injury; therefore, in accordance with the terms of the individual contract, as these medical claims qualify for primary coverage under workers compensation, the claims were denied as a work related injury and an Explanation of Benefits statement was issued to the consumer notifying them of this determination As the consumer has indicated in their complaint to your office, they have since provided their workers compensation insurance information to their medical providers so that these claims can be filed for consideration under that primary policyOnce the workers compensation carrier makes a determination on those claims, those determinations may then be submitted to PIC for reconsideration and coordination of benefits PIC then began receiving medical claims for another condition and requested information from the consumer in order to ascertain whether this condition was also a result of an accident or their work related injuryIn response, the consumer contacted our office and indicated that it was not, however, information that was provided to PIC by the consumer's physicians office indicated that this condition could be related to the work related injuryAs a result, the claims for this condition were denied as a work related injury The consumer recently contacted our office regarding this determinationBased on the information provided by the consumer, our customer service representative advised the consumer that they would have these claims reviewed and would follwith the consumerUpon review of the file, the claims and the information provided by the consumer, it was determined that this condition was not related to the work related injury and the claims for this condition were adjustedOur customer service representative attempted to contact the consumer to advise them of this, however, the telephone number provided was not answered and there was no voicemail on which to leave a message On October 1, our office mailed the consumer a written response to this complaint, which includes information regarding our findings, the outcome of our review and notice of the recent claim adjustmentsFollowing the claim adjustments, the consumer was also issued Explanation of Benefit statements that reflect the payment made on the adjusted claims If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at [redacted] or toll free at [redacted]
Initial Business Response /* (1000, 5, 2016/01/13) */
Our office has received an appeal regarding this matter directly from the ComplainantWe have notified the Complainant in writing that their appeal has been received and is being processed according to their Plans Appeal ProceduresAs
indicated in that letter, our office will issue the Complainant a written response to the appeal once the appeal review is completeIf the Complainant has any questions in the meantime, they may contact PreferredOne's Customer Service Department at *** or *** and request to speak with the Grievance Specialist assigned to her case
Initial Business Response /* (1000, 5, 2014/11/05) */
We are unable to identify this complainant with the information that they provided in their complaintPlease provide the full name of the covered member and their PreferredOne Subscriber ID # so that we may research and respond to this
complaintThank you
Initial Consumer Rebuttal /* (3000, 7, 2014/11/06) */
(The consumer indicated he/she DID NOT accept the response from the business.)
According to the Revdex.com guidelines, I am directed against providing personal identifiable informationThe response from PreferredOne has requested personal identifiable information that is not required based on the nature of my complaint (that searching for service providers without logging in with an ID provides provider information even when account sub category is properly identified)
Final Business Response /* (4000, 9, 2014/11/11) */
We have reviewed the concerns that you forwarded to our office and are able to provide you with the following information
PreferredOne Insurance Company ("PIC") offers various provider network options to our membersMembers do have the ability to search our provider network by either logging into their account by providing their member ID number or not providing their member ID number on our websiteHowever, if a member does not log into their account by providing their member ID number, the standard provider directory is displayed with the following disclaimer at the top of the provider search"PreferredOne has made this standard provider directory accessible by hand held devicesYour plan's network may differReview your plan documents for a more accurate listing."
If the consumer has any additional questions regarding this matter they are welcome to contact PreferredOne's customer service department at XXX-XXX-XXXX or toll free at X-XXX-XXX-XXXX
Final Consumer Response /* (3000, 11, 2014/11/12) */
(The consumer indicated he/she DID NOT accept the response from the business.)
We were using a personal computer and not a hand held device to search your listing
The number one listing after typing in our "Select" membership type and our zip code was a healthcare provider that is not covered under the "Select" type plan, only other plansIt is therefore our conclusion that your website is providing inaccurate information in order to avoid paying for claims
After discussing this issue with your customer service department, they repeated that their website will not show accurate information unless a client logs in using member ID and using a computer or laptop (mobile devices are known not to work)As we were using a personal computer that was not secure, we were not able to log in with an ID and therefore used the identifying membership type and zip code located on our membership card provided by PreferredOneThe result of this search was a list of service providers in our area that were listed as In-Networkweeks after receiving care from the in-network provider, we were told that they were actually out of network and are required to pay $The customer service representative stated that there was nothing they could do to fix this problem as it was human error on our behalf - when in reality it is a website error that PreferredOne will openly admit in customer service calls
Initial Business Response /* (1000, 5, 2016/03/09) */
Our office has notified this member of the coverage limitations and exclusions of their PlanOur office has also advised the member of their appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer
Service Department at *** or ***
Initial Consumer Rebuttal /* (3000, 7, 2016/03/09) */
(The consumer indicated he/she DID NOT accept the response from the business.)
I,Terry, was fully covered when this accident occurredIt was a simple emergency room visit involving stitching a long deep gash on my arm and stopping blood flowAt no point in time did I receive any correspondence from Preferred one concerning this ER nessessityThe only notice we received was a call from the ERROR that the bill was past dueAt that time my wife called Preferred one and was told that bill was "in system"Received call some time later from ER again saying they had resubmitted the bill to preferred one and still no paymentCalled preferred one again and man spoke with said yes it had been resubmitted actually another two times but unfortunately by then it was over time limitMan on phone from preferred one was informed that if it was over limit it was their inactivity and my wife asked to be transferred to a supervisorWife was informed that supervisor was unavailableWife asked for a call back from supervisorNone cameWife called back days in a row and "supervisor " was never "available"We have been told that preferred one is bad about ducking paymentsI am a manager for ABC Group and will be notifying corporate again concerning this non paymentIf need be we will also after all this point in time consult/hire an attorneyThis is insane and poor business practice how preferred one has mishandled this simple emergency room coverage
Final Business Response /* (4000, 9, 2016/03/11) */
At the time the services were rendered, PreferredOne Administrative Services was the third party administrator ("TPA") for the complainant's employer and provided administrative services with respect to their Plan until November 30, Our office has issued a written response directly to this complainant advising him to contact the Plan Sponsor and have also provided him with the name and phone number of the Plan Sponsor
Due to HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable to release information regarding the issue question without a signed HIPAA authorization from the member However, our office has contacted the member to discuss this matter and we
did advise the member of their appeal rightsIf the member has any additional questions, they may contact PreferredOne's Customer Service Department at ###-###-#### or ###-###-####
Our office has responded to an appeal regarding this matter directly from the ComplainantWe have notified the Complainant in writing of the decision regarding the appealIf the Complainant has any questions, they may contact PreferredOne's Customer Service Department at ###-###-#### or
###-###-#### and request to speak with the Grievance Specialist assigned to their appeal
Initial Business Response /* (1000, 5, 2016/01/13) */
Our office has received an inquiry regarding this matter directly from the Complainant. We have responded to the Complainant in writing. If the Complainant has any further questions, he may contact PreferredOne's Customer Service Department at...
[redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case.
Initial Consumer Rebuttal /* (2000, 7, 2016/01/14) */
(The consumer indicated he/she ACCEPTED the response from the business.)
The3 situation has been resolved.
The member/patient in this case is someone other than the party that has filed this complaint. Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release the patients protected health information. However, we can confirm that...
our office has been in direct contact with the member/patient and we have satisfactorily resolved their claim issue. If the member/patient has any additional questions about their claim, they may contact PreferredOne's Customer Service Department at ###-###-#### or ###-###-####. With regard to the complainants request for reimbursement of premiums paid, please be advised that the complainant is enrolled in a “self-insured” benefit plan that is sponsored and maintained by their employer (Plan Sponsor). This means that the Plan Sponsor (employer) collects and maintains their plans premiums and pays eligible medical claims from its own assets. While the Plan Sponsor (employer) contracted with PreferredOne to provide claim processing, pre-certification and other administrative services for their plan from January 1 - December 31, 2017, this did not include the collection of, or PreferredOne’s receipt of, their eligible employees medical premiums. Therefore, if the complainant has any outstanding concerns pertaining to their premium payments, they will need to address those concerns with their employer directly.
Initial Business Response /* (1000, 5, 2016/02/02) */
Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable to respond directly to you regarding the claim in question without a signed HIPAA authorization from the member.
However, our...
office has contacted the member to discuss this matter and we did advise the member of their appeal rights and we provided them with an Appeal Form to facilitate their filing of an appeal. If the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Initial Business Response /* (1000, 5, 2016/02/24) */
Due to the HIPAA privacy laws that pertain to the release of protected health information, PreferredOne is unable release information regarding the claims in question without a signed HIPAA authorization from the member.
However, our office...
has issued a written response to this complaint directly to our member. In addition to addressing their concerns, this response also included notice of their applicable appeal rights. If the member has any additional questions, they may contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Initial Consumer Rebuttal /* (3000, 7, 2016/02/26) */
(The consumer indicated he/she DID NOT accept the response from the business.)
We have received the response from Preferred One by mail today, February 26 2016. After a critical review of their response, we believe we have solid grounds to make a written appeal soonest, consistent with our rights specified on the letter. we will communicate directly with them in complete fairness and good faith. We will provide other documentation in our direct response to them to support our case, including, but not limited to, earlier visits in the same year at Allina Health which we have discovered and realized just now, were also not covered. Thank you.
Final Consumer Response /* (3000, 11, 2016/02/29) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Our response is only to physically acknowledge receipt of the letter dated February 23 2014 and this is very clear. WE NEVER SAID THAT WE HAVE ACCEPTED THEIR INITIAL RESPONSE - THAT IS AN ENTIRELY DIFFERENT STORY AND PLEASE DO NOT TRY TO TWIST IT! WHAT WE SAID IS THAT WE WILL APPEAL THEIR DECISION TO DENY THE CLAIM AND WILL COMMUNICATE DIRECTLY WITH THEM. AGAIN THIS IS NOT THE SAME AS ACCEPTING THEIR RESPONSE. THE APPEAL IS A FORM OF REBUTTAL IF YOU LIKE TO PUT IT THAT WAY.
Final Business Response /* (4000, 14, 2016/03/01) */
PreferredOne believes that it has appropriately responded to this consumers complaint to the extent possible at this time.
As previously communicated, PreferredOne has issued the consumer a direct response to their concerns and has provided them with appropriate direction and instruction regarding their right to address any further coverage concerns by initiating an appeal directly with our office. The consumer has acknowledged that they have received our response, has indicated that they agree to continue to address their coverage concerns with us directly and has stated that they are preparing to file an appeal with our office. Once that appeal has been received by our office, we will review the information presented and will respond to the consumer directly in accordance with their Plans appeal provisions.
Again, if the consumer has any additional questions or concerns in the meantime, they are welcome to contact PreferredOne's Customer Service Department at [redacted] or [redacted].
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.
Initial Business Response /* (1000, 5, 2014/09/25) */
Our records indicate that the complainant did contact our office regarding a concern pertaining to the coverage of her pharmacy claims and that she was referred to a Customer Service Manager.
The Customer Service Manager contacted the...
complainant's pharmacy and it was discovered that the pharmacy was submitting the claims(s) in question to the incorrect Pharmacy Benefit Manager (PBM), which was resulting in the claim denials. The Customer Service Manager worked with the pharmacy to re-submit the claim in question to the correct PBM and the claim processed successfully as a result.
The Customer Service Manager then contacted the complainant directly, provided this information and addressed her concerns. We understand that the complainant was satisfied. As was communicated to the complainant at that time, if she experiences any additional issues with the filing of her pharmacy claims, she is welcome to contact the Customer Service Manager directly for assistance.
I am rejecting this response because :I haven't received the information we discussed yet. Once I get what I requested I will accept.
Initial Business Response /* (1000, 5, 2014/11/26) */
Our office has received an appeal regarding this matter directly from the Complainant. We have notified the Complainant in writing that his appeal has been received and is being processed according to his Plans Appeal Procedures. As indicated in...
that letter, our office will issue the Complainant a written response to his appeal once the appeal review is complete. If the Complainant has any questions in the meantime, he may contact PreferredOne's Customer Service Department at [redacted] or [redacted] and request to speak with the Grievance Specialist assigned to his case.
Initial Consumer Rebuttal /* (3000, 7, 2014/12/09) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Because the business is taking to long to resolve this issue and in the meantime the Hospital is sending me notifications that my account is going to be reported to the credit bureau and place under delinquency.
Final Business Response /* (4000, 9, 2014/12/10) */
PreferredOne mailed our response to this consumers appeal on 12/4/14. If this consumer has any further questions on this issue, he should call PreferredOne directly.