December 16,
Accredited Business Services
Revdex.com Northwest
Re: Complaint ID: ***
To Whom It May Concern:
This letter is in
response to the complaint filed by a SelectHealth member regarding the payment of a colonoscopy
Preventive care, as defined by the Affordable Care Act and SelectHealth, is covered at percentPreventive services include examinations, immunizations, certain screening laboratory and x-ray tests, and procedures commonly accepted by clinicians which, when performed periodically, can detect disease conditions not known to currently exist in the person or which prevent the development of disease conditions in the case of immunizationsPreventive services include, but may not be limited to, such tests as screening mammography, colon and prostate cancer screening, flu and pneumonia vaccinations, Pap smears, and routine childhood immunizationsNot every preventive service is appropriate every yearSelectHealth may establish a schedule of yearly or multi-year intervals for the performance of specified preventive servicesIf a disease state exists for which the treatment of a condition prevents a subsequent condition (e.gtreating high blood pressure preventing a heart attack or stroke) and the purpose of the visit is to evaluate and manage this problem, it is not considered a preventive service
Colon cancer screening is the evaluation of a person of the appropriate age and risk (usually age and older in people at a risk, but younger in patients at high risk) through various means to evaluate for the presence of colon cancer when no cancer or other colon disease is already known to existThese services may include testing for blood in the stool (such as stool guaiac cards or immunofecal occult blood test (iFOBT)), sigmoidoscopy, or colonoscopyThe Affordable Care Act (ACA) and the United States Preventive Services Task Force (USPSTF) recommend screening sigmoidoscopies once every years and screening colonoscopies once every years
In the complaint, the member states that he/she was told that a colonoscopy would be covered at percentHowever, when the related claims were submitted, the facility billed the services as diagnostic, not preventive
As part of the investigation of the complaint, we re-reviewed the claims in questionAlthough the facility billed the service as diagnostic, the physician charges were billed as preventive careTherefore, in an effort to resolve this complaint, SelectHealth will adjust the facility claim to match what was billed by the physician
If you or the member have questions regarding this matter, please call me at 801-442-(Salt Lake area) or 844-208-
Sincerely,
Emily NJ***
Appeals Manager
SelectHealth
Attn: [redacted]
Revdex.com Resolutions Consultant
PO Box 1000
DuPont, WA 98327
Re: Complaint ID: [redacted]
Dear Ms. [redacted]:
This letter is in response to the...
complaint filed by a SelectHealth member regarding denial of a requested medication.
In the complaint, the member asserts that SelectHealth is denying coverage of a medication prescribed by his/her physician and is forcing the patient to try several other drugs before approving the requested medication.
Some drugs have special requirements that must be met before SelectHealth will cover them. There are certain drugs that require preauthorization to be covered by SelectHealth. Additionally, certain drugs require a provider to first prescribe an alternative drug preferred by SelectHealth. The alternative drug is generally a more cost-effective therapy that does not compromise clinical quality. This approach is known as step therapy. If a provider believes a patient requires a certain medication that normally requires step therapy and feels that the alternative drug does not meet the patient’s needs, the provider may request an exception through the preauthorization process. SelectHealth may cover the drug without step therapy if determined to be medically necessary.
Furthermore, if a member disagrees with a decision made by SelectHealth, he/she has the right to appeal the decision in writing to the following address:
SelectHealth
Attn: Appeals Department
PO Box 30192
Salt Lake City, UT 84029
Fax: 801-442-0792
Thank you for the opportunity to respond to this complaint. If you have additional questions regarding this matter, please call me at 844-208-9012.
December 29, 2016 Accredited Business Services Revdex.com Northwest Re: Complaint ID: [redacted] To Whom It May Concern: This letter is in response to the complaint filed by a SelectHealth member regarding the denial of a claim for services a dependent received in June 2016. The member...
in question indicates the denied claim is for services received after an automobile accident. The member asserts that the automobile insurance carrier paid their portion of the claims but SelectHealth is still not paying. Once an automobile carrier exhausts its benefit, a Personal Injury Protection (PIP) roster listing the providers and the amounts paid must be submitted to SelectHealth. Related claims are not paid until the necessary information is submitted. In this situation, the individual provider names were not listed on the PIP roster. Without this information SelectHealth is unable to correctly coordinate benefits. However, after further review, it has been confirmed that the automobile insurance benefits were exhausted on May 24, 2016. Therefore, any claims for services after that date will be adjusted and paid according to the benefits in effect at the time the services occurred. If the member has further questions regarding this matter, please contact me at 801-442-7650 (Salt Lake area) or 844-208-9012. Sincerely, Emily *. J[redacted] Appeals Manager SelectHealth
response to the complaint filed by a SelectHealth member regarding the termination of his/her policy.
Individual plan members may terminate their plan by giving SelectHealth advance written notice. Generally, the termination date is the end of the month in which the termination event or request occurs. However, SelectHealth may terminate coverage for nonpayment of applicable premiums or contributions. Termination may be retroactive to the beginning of the period for which premiums or contributions were not paid, and SelectHealth may recover the amount of any benefits a member received during the period of lost coverage.
The member in question asserts that the policy was erroneously terminated on June 30, 2016. Our records indicate that the member’s July 2016 premium was not received. On July 15, 2016, a letter was mailed to the member with notification that the premium was late, with instructions to pay the applicable premium before the last business day of July. Then, on July 18, 2016, the member submitted a change form to add a newborn dependent child. When a dependent is added to the plan, the premium rate is increased. On July 25, 2016, the member also submitted a request to terminate the dental benefits for the dependents covered by the plan. Terminating the dental benefits also changes the premium rate. While the member suggests a request to terminate the medical benefits was also submitted, there is no record of that request.
This member uses online billing to make premium payments. Because of the multiple changes to the policy, multiple billings with the change in premium for the medical benefits were sent to the member. Because no payment was made for July the plan terminated June 30, 2016 for non-payment of the applicable premium.
If the member has further questions regarding this matter, please contact me at 801-442-7650 (Salt Lake area) or 844-208-9012.
December 16,
Accredited Business Services
Revdex.com Northwest
Re: Complaint ID: ***
To Whom It May Concern:
This letter is in
response to the complaint filed by a SelectHealth member regarding the payment of a colonoscopy
Preventive care, as defined by the Affordable Care Act and SelectHealth, is covered at percentPreventive services include examinations, immunizations, certain screening laboratory and x-ray tests, and procedures commonly accepted by clinicians which, when performed periodically, can detect disease conditions not known to currently exist in the person or which prevent the development of disease conditions in the case of immunizationsPreventive services include, but may not be limited to, such tests as screening mammography, colon and prostate cancer screening, flu and pneumonia vaccinations, Pap smears, and routine childhood immunizationsNot every preventive service is appropriate every yearSelectHealth may establish a schedule of yearly or multi-year intervals for the performance of specified preventive servicesIf a disease state exists for which the treatment of a condition prevents a subsequent condition (e.gtreating high blood pressure preventing a heart attack or stroke) and the purpose of the visit is to evaluate and manage this problem, it is not considered a preventive service
Colon cancer screening is the evaluation of a person of the appropriate age and risk (usually age and older in people at a risk, but younger in patients at high risk) through various means to evaluate for the presence of colon cancer when no cancer or other colon disease is already known to existThese services may include testing for blood in the stool (such as stool guaiac cards or immunofecal occult blood test (iFOBT)), sigmoidoscopy, or colonoscopyThe Affordable Care Act (ACA) and the United States Preventive Services Task Force (USPSTF) recommend screening sigmoidoscopies once every years and screening colonoscopies once every years
In the complaint, the member states that he/she was told that a colonoscopy would be covered at percentHowever, when the related claims were submitted, the facility billed the services as diagnostic, not preventive
As part of the investigation of the complaint, we re-reviewed the claims in questionAlthough the facility billed the service as diagnostic, the physician charges were billed as preventive careTherefore, in an effort to resolve this complaint, SelectHealth will adjust the facility claim to match what was billed by the physician
If you or the member have questions regarding this matter, please call me at 801-442-(Salt Lake area) or 844-208-
Sincerely,
Emily NJ***
Appeals Manager
SelectHealth
July 27, 2016
Attn: [redacted]
Revdex.com Resolutions Consultant
PO Box 1000
DuPont, WA 98327
Re: Complaint ID: [redacted]
Dear Ms. [redacted]:
This letter is in response to the...
complaint filed by a SelectHealth member regarding denial of a requested medication.
In the complaint, the member asserts that SelectHealth is denying coverage of a medication prescribed by his/her physician and is forcing the patient to try several other drugs before approving the requested medication.
Some drugs have special requirements that must be met before SelectHealth will cover them. There are certain drugs that require preauthorization to be covered by SelectHealth. Additionally, certain drugs require a provider to first prescribe an alternative drug preferred by SelectHealth. The alternative drug is generally a more cost-effective therapy that does not compromise clinical quality. This approach is known as step therapy. If a provider believes a patient requires a certain medication that normally requires step therapy and feels that the alternative drug does not meet the patient’s needs, the provider may request an exception through the preauthorization process. SelectHealth may cover the drug without step therapy if determined to be medically necessary.
Furthermore, if a member disagrees with a decision made by SelectHealth, he/she has the right to appeal the decision in writing to the following address:
SelectHealth
Attn: Appeals Department
PO Box 30192
Salt Lake City, UT 84029
Fax: 801-442-0792
Thank you for the opportunity to respond to this complaint. If you have additional questions regarding this matter, please call me at 844-208-9012.
Sincerely,
Emily ** J[redacted]
Appeals Manager
SelectHealth
December 29, 2016 Accredited Business Services Revdex.com Northwest Re: Complaint ID: [redacted] To Whom It May Concern: This letter is in response to the complaint filed by a SelectHealth member regarding the denial of a claim for services a dependent received in June 2016. The member...
in question indicates the denied claim is for services received after an automobile accident. The member asserts that the automobile insurance carrier paid their portion of the claims but SelectHealth is still not paying. Once an automobile carrier exhausts its benefit, a Personal Injury Protection (PIP) roster listing the providers and the amounts paid must be submitted to SelectHealth. Related claims are not paid until the necessary information is submitted. In this situation, the individual provider names were not listed on the PIP roster. Without this information SelectHealth is unable to correctly coordinate benefits. However, after further review, it has been confirmed that the automobile insurance benefits were exhausted on May 24, 2016. Therefore, any claims for services after that date will be adjusted and paid according to the benefits in effect at the time the services occurred. If the member has further questions regarding this matter, please contact me at 801-442-7650 (Salt Lake area) or 844-208-9012. Sincerely, Emily *. J[redacted] Appeals Manager SelectHealth
December 21, 2016
Accredited Business Services
Revdex.com Northwest
Re: Complaint ID: [redacted]
To Whom It May Concern:
This letter is in...
response to the complaint filed by a SelectHealth member regarding the termination of his/her policy.
Individual plan members may terminate their plan by giving SelectHealth advance written notice. Generally, the termination date is the end of the month in which the termination event or request occurs. However, SelectHealth may terminate coverage for nonpayment of applicable premiums or contributions. Termination may be retroactive to the beginning of the period for which premiums or contributions were not paid, and SelectHealth may recover the amount of any benefits a member received during the period of lost coverage.
The member in question asserts that the policy was erroneously terminated on June 30, 2016. Our records indicate that the member’s July 2016 premium was not received. On July 15, 2016, a letter was mailed to the member with notification that the premium was late, with instructions to pay the applicable premium before the last business day of July. Then, on July 18, 2016, the member submitted a change form to add a newborn dependent child. When a dependent is added to the plan, the premium rate is increased. On July 25, 2016, the member also submitted a request to terminate the dental benefits for the dependents covered by the plan. Terminating the dental benefits also changes the premium rate. While the member suggests a request to terminate the medical benefits was also submitted, there is no record of that request.
This member uses online billing to make premium payments. Because of the multiple changes to the policy, multiple billings with the change in premium for the medical benefits were sent to the member. Because no payment was made for July the plan terminated June 30, 2016 for non-payment of the applicable premium.
If the member has further questions regarding this matter, please contact me at 801-442-7650 (Salt Lake area) or 844-208-9012.
Sincerely,
Emily N. J[redacted]
Appeals Manager
SelectHealth