On 12/5/15, Our Customer Service Department was able to reach the member and advise her that she is showing eligible back to 5/1/16. She will fax or call us about the billing information so we can reach out to the provider. Once that information is received, we will loop in our Claims...
Management team as this claim is past the timely filing deadline.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Mrs. [redacted]'s claims were, in fact, processed incorrectly. The CPT codes billed do not require an authorization and as such have been sent for reprocessing. Once theses claims have been reprocessed, Mrs. [redacted] will receive an explanation of benefits that will breakdown how these claims were paid. We...
apologize for the inconvenience. Should Mrs. [redacted] have any further questions or concerns, she may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Mr. [redacted] was enrolled at the date of service and his claims were denied in error. We reprocessed the two claims. The claim for date of service February 8, 2016 has not paid yet, but is currently being adjudicated. The second claim for date of service March 15, 2016 has been paid. We apologize for...
the inconvenience this has caused. Should Mr. [redacted] have any further questions he may contact Morgan G[redacted] at m[redacted]@mdwise.org or 317-822-7210.
MDwise does not make eligibility determinations. We contacted DFR and the State has opened her in Plus effective 4/1 in their system. I can confirm that member is open and has a $1 Power Account Payment from 4/1-on. Open means active coverage and she should begood to go.
We are in receipt of your letter dated April 21, 2015 notifying us of an issue reported from Ms. [redacted]. In her correspondence, Ms. [redacted] indicated that she continued to receive invoices from MDwise Marketplace even though she believes she did not enroll in a policy. We have...
cancelled Ms. [redacted]’s policy, and she should no longer receive invoices. Our Customer Service Team spoke with Ms. [redacted] today to let her know that her issue has been resolved. Please let me know if I can be of further assistance. Sincerely, Elizabeth E[redacted] MDwise Marketplace Compliance Officer
9/6/16 at 6:06 PM, had a lengthy conversation with the mbr. Attempted to explain to her that the state has made the ruling not to waived or credit the payment of $18.90 on her account. The mbr insisted that this has been going on for over a year and she still wants the $18.90 be remove from her...
account and this is someone else mistake and she does not wish to hear anything else. I advised the mbr, I will again look into account and will call her back. 9/7/2016 at 5:19 PM, outreached to the member, informed her again of the denied request. Advised for her to file an appeal with DFR to have her request be heard, the member agreed. The member than again stated that her request is now over a year old and due to someone else mistake the $18.90 should be removed from her account per her request. I attempted to explain again that her request is beyond what MDwise is able to do, the member than disconnect the call.
We have updated the accounts of Mr. and Mrs. [redacted] to reflect Dr. [redacted] as their PMP. We apologize for the delay in making this change. Should the [redacted]’s have any questions, they may contact me at mg[redacted]@mdwise.org or 317-822-7210.
The contact that Mr. [redacted] was working with was out of the office during the week of October 24 - 28. Mr. [redacted] was contacted on 10/31/2016 regarding his concerns. We are still trying to address his concerns with the hospital. We will continue to update Mr. [redacted] as we attempt resolution. Should Mr. [redacted] have any questions, he may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this response/resolution is satisfactory to me. My portal and 'my mdwise' page has been updated and mdwise has resubmitted the claims that showed, in error, that we did not have insurance.However, I still need to wait and see if my claims that have been resubmitted will go through and I would like to make sure that my husband, [redacted]'s account shows that he had met his deductable as it was noted on an earlier claim of his in July 2016.Thank You!
Regards,
[redacted]
We are in receipt of your letter dated August 14, 2015 notifying us of Problem Report #[redacted] from Ms. [redacted]. In her correspondence, Ms. [redacted] explained that several claims in May 2015 had not been paid. A MDwise Marketplace Bronze Plan was issued to Ms. [redacted] on 1/1/2015. ...
The MDwise Marketplace Claims Team researched this issue and discovered that the Center for Medicaid and Medicare Services (CMS) erroneously sent a 4/30/15 term record for Ms. [redacted]. The next record we received was for an enrollment span of 5/1/15 to 5/1/15, which essentially cancelled her coverage again. CMS then sent a correct enrollment record. As a result of incorrect records from CMS, Ms. [redacted]’s claims initially denied. Her claims have been re-processed, and the details are below. [redacted] is a contracted provider and is prohibited from balance billing Ms. [redacted]. Claim Number Date of Service Provider Billed Amount Allowed Amount Paid Amount Check Number Date Paid Member Responsibility [redacted] 5.11.15 [redacted] 158.00 138.96 119.51 (19.45 withheld for provider incentive program) 159017 8.27.15 0 [redacted] 5.11.5 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 [redacted] 5.11.15 [redacted] 93.00 39.75 0 na na 39.75 for deductible [redacted] 5.18.15 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 [redacted] 5.26.15 [redacted] 160.00 138.81 0 na na 138.81 for deductible [redacted] 5.26.15 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 Our Compliance Team spoke with Ms. [redacted] on 9/1/15 to update her on her account. The NAIC number for MDwise Marketplace is [redacted]. Please let us know if we can be of further assistance. Sincerely, Patty H[redacted] MDwise Marketplace General Counsel
Our Customer Service Department spoke to her yesterday and submitted a request to Provider Relations to help with the bills she is receiving (see attached). We were able to retro her eligibility to 5/1/16, allowing her claims to be covered. We need for the provider to resubmit, which is the purpose of the request to Provider Relations to assist with resubmission of the claims and waiving the timely filing for these so that the claims can be paid. I believe she filed the Revdex.com again because she interpreted the timely filing issue stated in our response to the Revdex.com as her failure to have the claims paid timely.
We looked into Ms. [redacted]’s concerns and found that there where claims that were denied as member not enrolled. Ms. [redacted] was enrolled at the date of service. The denied claims will be reprocessed. We will continue to update Ms. [redacted] on these claims as they are paid. Should Ms. [redacted] have...
any questions, she may contact Morgan [redacted] at 317-822-7210 or m[redacted]@mdwise.org.
MDwise has attempted to reach out to Mr. [redacted] at 11:10 AM, Tuesday, March 1, 2016 and left a voicemail with a direct number to a customer service manager for a return call. He also left messages at 3:15 PM, Tuesday, March 1, 2016 and 11:05 AM, Wednesday, March 2, 2016. As of...
today, we have not heard back from Mr. [redacted]. Mr. [redacted] became an active member with MDwise under the HIP Basic program on January 1, 2016. MDwise is required by the State to complete a Health Needs Screening for 70% of our members within 90 days of the date we receive notification that the member is eligible and active. The 90 day mark for Mr. [redacted] is March 30, 2016. MDwise is deeply committed to meeting our Service Level Agreements with the State. This is why the phone number for Mr. [redacted] was placed in our automatic dialer, along with the 1,144 other members reported active on January 1, 2016. During that time, our records indicate that Mr. [redacted] was contacted one time on February 29, 2016. He indicated to the customer service representative that he is ordering us to stop contacting him. Upon this notification, the phone number for Mr. [redacted] was entered into our Do Not Call list and removed from our automatic dialer system. The personal information of our members is never sold. Any information discussed during the Health Needs Screening is protected under the HIPAA and HITEC acts. The first question of the of the Screening also allows members to refuse sharing of the information with MDwise care management staff and the members provider if they so desire. The gift card referenced by Mr. [redacted] is accurate. By completing the Health Needs Screening, a member will earn 25 member reward points, which is enough to redeem for a $10 gift card. However, the members can also earn additional points throughout the year by setting up an online account with MDwise, tobacco cessation, completing their annual physical, and glucose testing, which could earn them enough points to redeem for a $50 gift card. The reward points and gift card are not a prize, but simply a way for MDwise to say thank you to our members for taking an active role in their health and well being. Please let me know if you have any questions.
Good afternoon, Ms. [redacted] is not fully eligible yet. MDwise has already sent a trigger file to the state noting member has made a payment so that her eligibility can be “triggered”. Her issue is on a list which is worked by folks from the state (FSSA). ...
MDwise sent another trigger last night and Ms. [redacted] is still not eligible. There is a chance she will be tomorrow. Again, MDwise does not have any control over how long it takes the state to process. The issue is communication to and from HP. FSSA fixes a member’s record, but it is not communicated to HP.Thank you,Allison
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me.
Regards,
[redacted]
The member had a change to their enrollment file from HealthCare.gov effective 4/16/2015 that contained an error and required a manual correction. Once the error was identified, the enrollment record was corrected and all pharmacy claims have been reprocessed. MDwise has ensured that the...
member’s coverage is active and up-to-date in all systems.MDwise works hard to identify any errors with incoming enrollment records from HealthCare.gov before our member’s care is impacted. Once an error is identified, it is our top priority to resolve the errors as expediently as possible. We regret that this member experienced problems with payment of their pharmacy claim, and are pleased that we were able to resolve the member’s issue to ensure correct claims processing going forward.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I was contacted by Morgan G[redacted] and she told me she was faxing a settlement offer to the hospital.After leaving many messages for Morgan over a weeks period of time and not getting any response, I decided to call the hospital.The hospital never received any communication from MDwise at all.Since then, I have left many more messages, both email and phone for Morgan...........She will not contact me.Please have someone call me and let me know whats going on...PLEASE
Regards,
[redacted]
We spoke with Mr. [redacted] about his concerns. While MDwise Marketplace paid the claims for this out of network provider at an in network rate due to their emergent nature, the provider is balance billing Mr [redacted] for hte remainder of the fees. We are working with the provider to ensure that Mr....
[redacted] is not balanced billed. We will continue to keep Mr. [redacted] informed as we address his concerns. Should Mr. [redacted] have any questions, he may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this response/resolution is satisfactory to me.
Regards,
[redacted]
On 12/5/15, Our Customer Service Department was able to reach the member and advise her that she is showing eligible back to 5/1/16. She will fax or call us about the billing information so we can reach out to the provider. Once that information is received, we will loop in our Claims...
Management team as this claim is past the timely filing deadline.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Mrs. [redacted]'s claims were, in fact, processed incorrectly. The CPT codes billed do not require an authorization and as such have been sent for reprocessing. Once theses claims have been reprocessed, Mrs. [redacted] will receive an explanation of benefits that will breakdown how these claims were paid. We...
apologize for the inconvenience. Should Mrs. [redacted] have any further questions or concerns, she may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Mr. [redacted] was enrolled at the date of service and his claims were denied in error. We reprocessed the two claims. The claim for date of service February 8, 2016 has not paid yet, but is currently being adjudicated. The second claim for date of service March 15, 2016 has been paid. We apologize for...
the inconvenience this has caused. Should Mr. [redacted] have any further questions he may contact Morgan G[redacted] at m[redacted]@mdwise.org or 317-822-7210.
MDwise does not make eligibility determinations. We contacted DFR and the State has opened her in Plus effective 4/1 in their system. I can confirm that member is open and has a $1 Power Account Payment from 4/1-on. Open means active coverage and she should begood to go.
We are in receipt of your letter dated April 21, 2015 notifying us of an issue reported from Ms. [redacted]. In her correspondence, Ms. [redacted] indicated that she continued to receive invoices from MDwise Marketplace even though she believes she did not enroll in a policy. We have...
cancelled Ms. [redacted]’s policy, and she should no longer receive invoices. Our Customer Service Team spoke with Ms. [redacted] today to let her know that her issue has been resolved. Please let me know if I can be of further assistance. Sincerely, Elizabeth E[redacted] MDwise Marketplace Compliance Officer
9/6/16 at 6:06 PM, had a lengthy conversation with the mbr. Attempted to explain to her that the state has made the ruling not to waived or credit the payment of $18.90 on her account. The mbr insisted that this has been going on for over a year and she still wants the $18.90 be remove from her...
account and this is someone else mistake and she does not wish to hear anything else. I advised the mbr, I will again look into account and will call her back. 9/7/2016 at 5:19 PM, outreached to the member, informed her again of the denied request. Advised for her to file an appeal with DFR to have her request be heard, the member agreed. The member than again stated that her request is now over a year old and due to someone else mistake the $18.90 should be removed from her account per her request. I attempted to explain again that her request is beyond what MDwise is able to do, the member than disconnect the call.
We have updated the accounts of Mr. and Mrs. [redacted] to reflect Dr. [redacted] as their PMP. We apologize for the delay in making this change. Should the [redacted]’s have any questions, they may contact me at mg[redacted]@mdwise.org or 317-822-7210.
The contact that Mr. [redacted] was working with was out of the office during the week of October 24 - 28. Mr. [redacted] was contacted on 10/31/2016 regarding his concerns. We are still trying to address his concerns with the hospital. We will continue to update Mr. [redacted] as we attempt resolution. Should Mr. [redacted] have any questions, he may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this response/resolution is satisfactory to me. My portal and 'my mdwise' page has been updated and mdwise has resubmitted the claims that showed, in error, that we did not have insurance.However, I still need to wait and see if my claims that have been resubmitted will go through and I would like to make sure that my husband, [redacted]'s account shows that he had met his deductable as it was noted on an earlier claim of his in July 2016.Thank You!
Regards,
[redacted]
We are in receipt of your letter dated August 14, 2015 notifying us of Problem Report #[redacted] from Ms. [redacted]. In her correspondence, Ms. [redacted] explained that several claims in May 2015 had not been paid. A MDwise Marketplace Bronze Plan was issued to Ms. [redacted] on 1/1/2015. ...
The MDwise Marketplace Claims Team researched this issue and discovered that the Center for Medicaid and Medicare Services (CMS) erroneously sent a 4/30/15 term record for Ms. [redacted]. The next record we received was for an enrollment span of 5/1/15 to 5/1/15, which essentially cancelled her coverage again. CMS then sent a correct enrollment record. As a result of incorrect records from CMS, Ms. [redacted]’s claims initially denied. Her claims have been re-processed, and the details are below. [redacted] is a contracted provider and is prohibited from balance billing Ms. [redacted]. Claim Number Date of Service Provider Billed Amount Allowed Amount Paid Amount Check Number Date Paid Member Responsibility [redacted] 5.11.15 [redacted] 158.00 138.96 119.51 (19.45 withheld for provider incentive program) 159017 8.27.15 0 [redacted] 5.11.5 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 [redacted] 5.11.15 [redacted] 93.00 39.75 0 na na 39.75 for deductible [redacted] 5.18.15 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 [redacted] 5.26.15 [redacted] 160.00 138.81 0 na na 138.81 for deductible [redacted] 5.26.15 [redacted] 39.00 12.74 10.32 (2.42 withheld for provider incentive program) 159012 8.27.15 0 Our Compliance Team spoke with Ms. [redacted] on 9/1/15 to update her on her account. The NAIC number for MDwise Marketplace is [redacted]. Please let us know if we can be of further assistance. Sincerely, Patty H[redacted] MDwise Marketplace General Counsel
Our Customer Service Department spoke to her yesterday and submitted a request to Provider Relations to help with the bills she is receiving (see attached). We were able to retro her eligibility to 5/1/16, allowing her claims to be covered. We need for the provider to resubmit, which is the purpose of the request to Provider Relations to assist with resubmission of the claims and waiving the timely filing for these so that the claims can be paid. I believe she filed the Revdex.com again because she interpreted the timely filing issue stated in our response to the Revdex.com as her failure to have the claims paid timely.
We looked into Ms. [redacted]’s concerns and found that there where claims that were denied as member not enrolled. Ms. [redacted] was enrolled at the date of service. The denied claims will be reprocessed. We will continue to update Ms. [redacted] on these claims as they are paid. Should Ms. [redacted] have...
any questions, she may contact Morgan [redacted] at 317-822-7210 or m[redacted]@mdwise.org.
MDwise has attempted to reach out to Mr. [redacted] at 11:10 AM, Tuesday, March 1, 2016 and left a voicemail with a direct number to a customer service manager for a return call. He also left messages at 3:15 PM, Tuesday, March 1, 2016 and 11:05 AM, Wednesday, March 2, 2016. As of...
today, we have not heard back from Mr. [redacted]. Mr. [redacted] became an active member with MDwise under the HIP Basic program on January 1, 2016. MDwise is required by the State to complete a Health Needs Screening for 70% of our members within 90 days of the date we receive notification that the member is eligible and active. The 90 day mark for Mr. [redacted] is March 30, 2016. MDwise is deeply committed to meeting our Service Level Agreements with the State. This is why the phone number for Mr. [redacted] was placed in our automatic dialer, along with the 1,144 other members reported active on January 1, 2016. During that time, our records indicate that Mr. [redacted] was contacted one time on February 29, 2016. He indicated to the customer service representative that he is ordering us to stop contacting him. Upon this notification, the phone number for Mr. [redacted] was entered into our Do Not Call list and removed from our automatic dialer system. The personal information of our members is never sold. Any information discussed during the Health Needs Screening is protected under the HIPAA and HITEC acts. The first question of the of the Screening also allows members to refuse sharing of the information with MDwise care management staff and the members provider if they so desire. The gift card referenced by Mr. [redacted] is accurate. By completing the Health Needs Screening, a member will earn 25 member reward points, which is enough to redeem for a $10 gift card. However, the members can also earn additional points throughout the year by setting up an online account with MDwise, tobacco cessation, completing their annual physical, and glucose testing, which could earn them enough points to redeem for a $50 gift card. The reward points and gift card are not a prize, but simply a way for MDwise to say thank you to our members for taking an active role in their health and well being. Please let me know if you have any questions.
Good afternoon, Ms. [redacted] is not fully eligible yet. MDwise has already sent a trigger file to the state noting member has made a payment so that her eligibility can be “triggered”. Her issue is on a list which is worked by folks from the state (FSSA). ...
MDwise sent another trigger last night and Ms. [redacted] is still not eligible. There is a chance she will be tomorrow. Again, MDwise does not have any control over how long it takes the state to process. The issue is communication to and from HP. FSSA fixes a member’s record, but it is not communicated to HP.Thank you,Allison
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution would be satisfactory to me.
Regards,
[redacted]
The member had a change to their enrollment file from HealthCare.gov effective 4/16/2015 that contained an error and required a manual correction. Once the error was identified, the enrollment record was corrected and all pharmacy claims have been reprocessed. MDwise has ensured that the...
member’s coverage is active and up-to-date in all systems.MDwise works hard to identify any errors with incoming enrollment records from HealthCare.gov before our member’s care is impacted. Once an error is identified, it is our top priority to resolve the errors as expediently as possible. We regret that this member experienced problems with payment of their pharmacy claim, and are pleased that we were able to resolve the member’s issue to ensure correct claims processing going forward.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that the response would not resolve my complaint. For your reference, details of the offer I reviewed appear below.
I was contacted by Morgan G[redacted] and she told me she was faxing a settlement offer to the hospital.After leaving many messages for Morgan over a weeks period of time and not getting any response, I decided to call the hospital.The hospital never received any communication from MDwise at all.Since then, I have left many more messages, both email and phone for Morgan...........She will not contact me.Please have someone call me and let me know whats going on...PLEASE
Regards,
[redacted]
We spoke with Mr. [redacted] about his concerns. While MDwise Marketplace paid the claims for this out of network provider at an in network rate due to their emergent nature, the provider is balance billing Mr [redacted] for hte remainder of the fees. We are working with the provider to ensure that Mr....
[redacted] is not balanced billed. We will continue to keep Mr. [redacted] informed as we address his concerns. Should Mr. [redacted] have any questions, he may contact Morgan G[redacted] at mg[redacted]@mdwise.org or 317-822-7210.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this response/resolution is satisfactory to me.
Regards,
[redacted]