Presbyterian Healthcare Services

March 25, 2016RE: Complaint # ***Customer: *** ***Dear Revdex.com:According to the Presbyterian Financial Billing Offices the claim for the services provided to patient (*** *** ***) by the Presbyterian Healthcare Services (PHS) at the Santa Fe Clinic on date of
service 12/24/has been sent to the Patient's insurance company (*** *** ***) on 03/23/via fax to: (***) ***.If the consumer Mr*** *** wants confirmation from his insurance Company (*** *** ***) that the claim has been processed he would need to contact them directly for this information or document.I hope that this addresses the consumers concerns per his desired outcome indicated on the complaint filed with your offices.Thank you,Geri *M***, Regulatory CoordinatorEnterprise Wide Complaint Management DepartmentAppeals/GrievancesPresbyterian Health Plan/Healthcare Services

January 19, 2016
Mr. [redacted],
This is in response to your most recent rejection to
Presbyterian Health Plan’s response through the Revdex.com Office.
According to our appeal records, your
Administrative Grievance Reconsideration Committee Review Hearing that was
filed on 06/30/15 was cancelled on 09/17/15 as the Presbyterian Health Plan’s
Level II Appeal Hearing Coordinator did not hear from you to schedule your appeal
hearing. (Attached September 17, 2015 Level II Appeal Hearing correspondence).The information that you provided in your
previous rejection to the Revdex.com was feedback that was provided and I will not be
receiving a decision back to provide you. 
This was merely feedback you provided regarding the classification of continuous
glucose monitor sensors.  As advised in
the previous rejection response, Presbyterian Health Plan administers this
benefit throughout the health plans book
of business for all groups and membership. 
The classification for this item is consistent for ALL our benefit plans and cannot be changed at this
time.  Your employer group would have to
change it for all [redacted] members. This is why you were advised
to go to your Benefit Administrator for the [redacted] and again this is not an issue of
formulary versus non-formulary as you advised in previous Revdex.com rejections. In regards to your rejection pertaining to the
New Mexico Superintendent of Insurance, their offices may not be able to
intervene and change the classification of a service or supply; however, they
have jurisdiction over a monetary issue when a commercial health plan member is
disputing cost-share for a service or supply. 
And in this case, this would apply and this would be the appropriate regulatory
process to take pertaining to your dispute. Once you’ve completed the internal appeal
process with Presbyterian Health Plan your next level of appeal is with their
offices.  The last Administrative Grievance that Ms. Liz
M[redacted] with Presbyterian Appeals reviewed and closed on 01/05/16 has provided you with the
Administrative Grievance Reconsideration Committee Hearing Level II Appeal rights.  You still have the right to continue on with
this process for this case.  You just
need to send in the form attached to your letter to request this appeal panel hearing or contact the Level II Appeal Hearing Coordinator at the telephone number listed in the decision letter.
Once again, please know that I cannot change a benefit or a
structure on how a service and/or supply is categorized and billed for service
and what the member’s cost-share is applied; therefore, I’m unable to reverse
the "denial".  You must follow the
processes at Presbyterian Health Plan.
Thank you,
Geri M[redacted]
Regulatory Coordinator
Presbyterian Health Plan

Dear Revdex.com: Ms. [redacted] concerns have been forwarded to our Provider Network Management Department and to New Mexico Orthopedics. The balance being charged to Ms. [redacted] is correct, the $23.00 charged for each visit on September 23, 2015, October 02, 2015 and October 09, 2015 is a...

coinsurance in addition to the $50.00 specialist copay, which is member’s responsibility. However, the claims were paid to New Mexico Orthopedics incorrectly and it took some time to correct. This was the reason Ms. [redacted] was billed a year and a half later. New Mexico Orthopedics has decided to make an adjustment regarding the charges owed ($69.00/$23.00 per visit) allowing a zero balance. The adjustment will take approximately three weeks to complete.

Complaint: [redacted]
I am rejecting this response because:Dear Revdex.com:The purpose of this e-mail is to request that my Complaint, ID#[redacted], be reopened and reinstated as Active and Unresolved as of today, April 8, 2016.  This request is based on a mis-communication, on April 6, 2016, between the Revdex.com and me as described below:On March 6, 20164:57:14PM, I received an Email(ODR) from Revdex.com of New Mexico, Subject:  Relay the rejection response from the business to the consumer.  The Message From Business to the Revdex.com, on April 4, 2016 states: ..."The complaint involves more review based on the complexity of the concerns addressed by the consumer.  We need more information from the consumer in order to fully address this issue.  Ms. Stacey S[redacted], Presbyterian's EWCMGrievance Research Specialist assigned to this case has tried reaching the consumer with no success.  If you are in contact with the consumer Ms. [redacted] if you can please have her contact Stacy at ###-###-#### directly to discuss these concerns so that we can review this matter.  Once we speak with the consumer and gather more information, Presbyterian Health Plan will need more time to fully respond to this complaint.  Thank you."This Email is from Geri A. M[redacted], Regulatory Coordinator, Enterprise Wide Complaint Management, Presbyterian Health Plan.In acknowledgment of and agreement with  Ms. M[redacted]'s request for more time to review my complaint, I submitted my response to Revdex.com, via Email (ODR), using Revdex.com's default letter TO: Revdex.com of New Mexico, Subject: I accept the business's response to resolve this complaint - Date Sent: 4/6/2016  9:25:45PM.  The Revdex.com default letter states:  "A default letter is provided here which indicates your acceptance of the business's  response.  If you wish, you may update it before sending it."  Additionally, the Revdex.com default letter states:  "I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me." I updated the default letter by adding: "Specifically, I will contact Stacey S[redacted], at [redacted], on Thursday, April 7, 2016, before Close of Business.  Regards, [redacted]."  This is where the mis-communication took place.  I merely agreed to Ms. M[redacted]'s request to call Ms. S[redacted] directly at ###-###-#### to discuss their concerns so they can fully review my complaint.As I stated in my response to Revdex.com, I indeed called Ms. S[redacted] on Thursday, April 7, 2016.  Ms. S[redacted] informed me that my complaint will be reviewed internally by either Mr. Jim G[redacted] (Medicare Internal Sales Manager) or  Mr. A[redacted] (Senior Representative for Federal Employees).  Additionally, that I should expect a telephone call from one of them.  At that point, I recommended that their questions be submitted to me in a simple, user-friendly Email format, (rather than a more complex attachment, as submitted before), to avoid potential mis-communication.When I inquired about status of audit claims I have paid from June, 1, 2010- present, Ms. S[redacted] advised that several have been reviewed and adjusted and the remainder have not been completed.Additionally, Ms. S[redacted] informed me that it is my responsibility to setup the Automatic Crossover to Medicare to process my Part B, Supplemental Medical  Claims payments.  I immediately repeated that Medicare Claims Agents made it clear to me that (BY MEDICARE LAW), only Presbyterian Plan staff is AUTHORIZED to set-up my request for an AUTOMATIC CROSSOVER to Medicare, or crossovers in general. This is consistent with my Response to Business Letter dated March 25, 2016, which Revdex.com has acknowledge received.Finally, Ms. S[redacted] repeated that Presbyterian has enrolled me in its ECRS database for Medicare Advantage Members.  I again referred her to my March 25, 2016 Letter in which I informed them that I am officially enrolled in (ORIGINAL) Medical PARTS A & B only, and that switching my coverage to any other enrollment plan has very serious consequences, both legally and financially.  An Automatic Crossover to Medicare is designed to avoid such mistakes as these.I'm simply trying to be helpful.Regards,[redacted]
[To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the response. If the consumer does not provide a reason the complaint will be closed Answered]

April 4, 2016Dear Revdex.com:Presbyterian Health Plan is in receipt of the rejection filed by the consumer Ms. [redacted] for complaint # [redacted].The complaint involves more review based on the complexity of the concerns addressed by the consumer.  We need more information from the consumer in order to fully address this issue. Ms. Stacey S[redacted], Presbyterian's EWCM Grievance Research Specialist assigned to this case has tried reaching the consumer with no success. If you are in contact with the consumer Ms. [redacted] if you can please have her contact Stacy at ###-###-#### directly to discuss these concerns so that we can review this matter.Once we speak with the consumer and gather more information, Presbyterian Health Plan will need more time to fully respond to this complaint.Thank you,Geri *. M[redacted], Regulatory CoordinatorEnterprise Wide Complaint ManagementPresbyterian Health Plan

In
response to Ms. [redacted]'s  concerns, we have contacted the Care Team Coordinator with
Presbyterian Health Plan Claims Coordination of Benefits department for review.
The Care Team Coordinator advises that her Part B Supplemental Insurance or
Crossover to Medicare billing...

in Presbyterian’s database has been updated to
reflect the date of 06/01/2010. It is my understanding; it is the member’s
responsibility to advise Medicare of this change. Ms. [redacted] can reach Medicare
Coordination of Benefits at ###-###-####, to give them this updated
information. This information has also be entered into the Electronic
Correspondence Referral System (ECRS), which is a database used for Medicare
contractors to exchange information with Medicare Advantage members.
Additionally, we have contacted a Specialist with Presbyterian Health Plan
Claims Care Unit regarding her request to have an audit of your claims from
June 2010 to present. After completion of the audit; we have determined that an
Explanation of Benefits (EOB) is necessary for the following claims. The EOB's have been requested, and once this information is
received we will submit the EOB's to the Claims Care Unit for re-processing of these
claims:
Date
of service: 2010
Claim
#: [redacted]
Claim
#: [redacted]
Date
of service: 2011
Claim
#: [redacted]
Date
of service: 2013
Claim
#: [redacted]
Date
of service: 2015
Claim
#: [redacted]

Dear Sir/Madam, Attached is the signed HIPAA release form you requested regarding complaint ID [redacted].  I also sent a fax with this information for your convenience. Thank You, [redacted]-

December 22, 2015Mr. [redacted],Presbyterian Health Plan is in receipt of the complaint...

that you filed with the Revdex.com comlaint # [redacted].  According to our records, you have filed previous complaints and appeals with Presbyterian Health Plan regarding this matter pertaining to the classification of continous glucose monitor sensors.  Your previous grievances and appeals have been addressed in May 2015, June 2015 and currently we have a new appeal that we received on December 18, 2015 for dispute with claim cost-share and classification for services provided by [redacted] on 11/30/15.Presbyterian Health Plan has responded to your appeals and grievances previously and currently is reviewing the appeal filed on 12/18/15.  You will be receiving a written response to your appeal on or before January 5, 2016 regarding this new recent Administrative Grievance (appeal) filed.Thank you,Geri A. M[redacted]Regulatory Appeals & Grievance CoordinatorPresbyterian Health PLan

Mr. [redacted],
This is in response to your rejection to Presbyterian Health
Plan’s response through the Revdex.com Offices.
Thank you for your detailed response.  Please know that we do appreciate your
valuable feedback and have certainly passed this information on to the
appropriate departments at Presbyterian Health Plan.  With that being said, the Presbyterian Health
Plan’s Marketing and Pharmacy Department have researched this matter very thoroughly
and have determined that Presbyterian Health Plan administers continuous glucose
monitor sensors as a durable medical equipment 
service/supply.  Presbyterian
Health Plan administers this benefit throughout the health plans book of
business for all groups and membership.  The
classification for this item is consistent for all our benefit plans.  In addition, this is not a formulary versus
non-formulary issue. 
Additionally, you certainly have the right to continue on to
a Level  II Appeal- Administrative
Grievance Reconsideration Committee Panel Review Hearing pertaining to the
uphold decision rendered on 01/05/16. This is a New Mexico Superintendent Insurance regulatory process that
health plan members are offered through the appeal process if they have a monetary cost-share dispute. Please know that I
cannot change a benefit or a structure on how a service and/or supply is
categorized and billed for service and what the member’s cost-share is applied;
therefore, I’m unable to reverse the denial as you have requested.
Thank you,
Geri M[redacted]
Regulatory Coordinator
Presbyterian Health Plan

June 17, 2016
RE: Complaint # [redacted]
Dear Revdex.com:
Presbyterian Healthcare Services received complaint # [redacted] and have reviewed and responded to Ms. [redacted] complaint.
Please find attached complaint closure letter sent to...

Ms. [redacted] on 06/10/16.
In addition, the Presbyterian Healthcare Services EWCM Coordinator advised that normally, charges are not discussed with patients during their visit as the staff does not know the full extent of the charges. Ms. [redacted] received the appropriate services and the labs were necessary to diagnose her condition. The charges were reviewed to determine accuracy and the charges are correct. We apologized that she felt the charges were high and usually we review our charges annually which are competitive within the market. Based on our review, we are unable to adjust the charges as they were billed appropriately.
The EWCM Presbyterian Healthcare Services EWCM Coordinator suggested that Ms. [redacted] appeal with her insurance carrier Blue Cross Blue Shield (BCBS) or inquire on why her insurance left her with such a high balance. In addition, Ms. [redacted] was also referred to the Presbyterian Healthcare Services Patient Financial Services Department to set-up a payment plan at ###-###-####.
Thank you,
Geri A. M[redacted]
Regulatory Coordinator
Presbyterian Health Plan/Healthcare Services

Dear Revdex.com,We have sent a written resolution letter directly to the patient regarding this issue. Unfortunately, due to HIPAA Privacy rules I am unable to disclose any additional information. However, the concerns have been resolved. Thank youJana M, CoordinatorPresbyterian HealthCare...

Services Complaint Services[redacted]
*

Hello,We are in receipt of this grievance and will reach out to the patient today. On 8/17/17 we will provide a brief outcome of our resolution to the Revdex.com and the patient.Sincerely,Jana M[redacted], CoordinatorPresbyterian Delivery Systems Complaint Services[redacted]...

[redacted]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
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.
Regards,
[redacted]

Dear Revdex.com,We have responded directly to the patient in writing and verbally regarding this issue. Unfortunately  due to  HIPAA privacy rules I am unable to disclose any additional information.  Sincerely, Jana M[redacted], CoordinatorPatient Relations Support ServicesPhone: [redacted]...

[redacted] -Fax: [redacted]
[redacted]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
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.
Regards,
[redacted]

The issue has been resolved. This was communicated to the patient verbally and he will receive a response in writing as well. Due to HIPAA guidelines we are unable to provide any information about the outcome of our review. Thank youJana M[redacted], CoordinatorPresbyterian Patient Relations...

Support ServicesP[redacted]

Complaint: [redacted]
I am rejecting this response because: Firstly, although Ms. M[redacted] states that they do not have "the automatic cross system" I have requested, that does not mean that they can set one up as I have  request.   As a matter of fact, Medicare agents have recommended it to me, when they notified me that their claims database shows no record of my Part B, Supplemental Insurance.  The procedures for setting it up is included in Medicare.gov website; there's a sections on "crossovers."  Secondly, I have repeatedly been told by Ms. Stacey S[redacted] (both in a letter she mailed to me, and when I spoke to her by phone, recently).  that they have switched my Part B enrollment FROM: Presbyterian Federal  Health  Plan, Enrollment: High Option, Self Only, Enrollment Code P21, TO: an Advantage Plan.  First and foremost, that is unlawful, because no one has the authority  to change my medical insurance coverage but me.  I have repeatedly  asked in my previous Revdex.com response by mail and in my last phone conversation with Ms. S[redacted] that such action is not accurate and should be immediately taken out of that system.   Ms. M[redacted] 's response does not even mention this very  serious situation.    Until,  I receive official notification, through this Revdex.com response system, that they  have corrected this most serious situation they have created  I will not accept business response    Thirdly,  Ms. M[redacted]'s business response also failed to even mention my  original and  still active request to conduct an audit of all Presbyterian bills I have paid from June 1, 2010 until the present.  Ms. S[redacted] identified which claims were being reviewed in her letter she  mailed to me recently.   I have retained her letter in  my personal, complaint file.  Final response.  I do not accept business response.
Regards,
[redacted] [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the response. If the consumer does not provide a reason the complaint will be closed Answered]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
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. I received a call from Presbyterian Hospital earlier this week regarding this dispute. They verbally indicated that the problem was due to their manual billing system and that my account would be adjusted to indicate that the amount was no longer owed.  I asked them to please send a written summary of these actions so I would have proper documentation should I receive another bill in the future.  I received the updated billing summary yesterday which indicated that the amount ($293.51) was an administrative patient write off dated 8/11/17.  Thank you very much for helping me promptly resolve this dispute.
Regards,
[redacted]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
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.   Specifically, I will contact Stacy S[redacted], at ###-###-####, on Thursday, April 7, 2016, before Close of Business.
Regards,
[redacted]

Complaint: [redacted]
I am rejecting this response because:  1) AN AUTOMATIC CROSSOVER TO MEDICARE FOR MY PART B, SUPPLEMENTAL INSURANCE BILLING HAS NOT BEEN  RESPONDED TO , IN THEIR BUSINESS RESPONSE  AND 2) The Presbyterian Care Team  Coordinator has created a catastrophic  mistake (BY SWITCHING MY CURRENT  ENROLLMENT  IN ORIGINAL MEDICARE (FOR PARTS A &B  ONLY)  TO  THEIR DATABASE  FOR  MEDICARE ADVANTAGE  MEMBERS,  WHICH  IS TOTALLY INCORRECT.I mailed a handwritten, more detailed response to your office on Friday, March 25, 2015, since my home computer was not operational at that time. It is now operational.Regards,
[redacted] [To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the response. If the consumer does not provide a reason the complaint will be closed Answered]