Dear Ms***:I am very disappointed that *** *** Sr Appeals Specialist for Medical Mutual would make a statement that Metrohealth agreed that a refund was dueI received a letter from Metrohealth 05/11/asking me to contract Medical Mutual to advice them that Medical Mutual is the primary insurance and the claim is not a BWC claim(Attached)This letter was faxed to Medical Mutual 05/29/and 06/01/along with copies of Z*** Insurance copolicy (attached) stating they were a secondary insurance and the policy is not a BWC policy.Therefore Medical Mutual and its Vender Auditor made the decision to make it a BWC claim without a BWC claim number or proof that I filed a BWC claimIt is my opinion that Medical Mutual is trying to get out of paying claims simply because a secondary insurance company is involved.My contract with Medical Mutual covers me as a primary insurer regardless of what I am doing and they should pay claims as contracted without inconvenience to my providers that reflects meThere actions has caused a conflict with one of my providers *** *** causing the cancelation of appointments for me and my daughter due to them retracting payments for non BWC claims.In closing they should pay all claims as contracted and contact me in the future if they have questions about a claimAn apology would be appreciated for destroying provider relationships but 'I'm sure that won't happen
Dear Ms***:I am writing in response to your letter dated November 30, 2015, regarding the member’s right to file an appeal in the case of an adverse claim determinationPlease refer to the below section from the member’s Ohio Public Employee Retirement System (OPERS) Medical Plan Description:Introduction, which states: you must enroll in Medicare the first day you become eligibleIf you or any of your eligible dependents are eligible for Medicare but do not enroll, this Plan's coverage for covered hospital (Medicare A) and/or medical (Medicare B) expenses will be reduced by the amount Medicare would have paidThis will be done whether or not you actually enroll in the Medicare program.Helpful Notes, which states: as soon as you are eligible for any type of Medicare, you MUST sign up for it, notify OPERS of your enrollment and use itIf you don't, it will cost you a lot of your own moneyThere are some exceptions, but until you hear otherwise from OPERS, assume this rule is always true.In accordance with the plan benefits, the member does have the right to appeal an adverse claim determinationMedical Mutual is not denying the member their right to appeal. If Medical Mutual had received an appeal, the denial would have been upheld based on the above requirementsIf the member would have been enrolled in Medicare Part B, as required by the Group, Medicare would have paid percent of their Allow Amount for the home visitsTherefore, no benefit would have been due under the OPERS plan. Medical Mutual administers the benefits onlyMedical Mutual is not permitted to change or alter any membership and/or eligibility requirements established by the GroupAttached is the Medical Plan DescriptionIf you have any questions, please don’t hesitate to contact me. Sincerely,*** *** Sr Appeals SpecialistMember Appeals department
In response to your email inquiry dated 7/6/15, the Off-Exchange Standard Classic Platinum plan was not offered for and is currently not available. Sincerely,*** ***Member Appeals department
May 18, *** *** Revdex.com Euclid Ave., 4th Floor Cleveland, Ohio 44115- Case ID: *** *** *** Dear Ms***: I am writing in response to your letter dated May 27, 2016, regarding dental coverage and waiting periods Effective
11/1/15, the member elected the non-group Dental Plan In accordance with the terms of the contract, Dental Benefits, it states: some services may not be covered until an individual has been insured under the plan for a certain period of time, known as a waiting periodRefer to the Schedule of Benefits to determine if any services are subject to a waiting periodThe Schedule of Benefits for Covered Persons Ages and Over shows that Basic Services are subject to a month waiting period and Major Services are subject to a month waiting periodTherefore, the waiting period will not be waived and the member may be held responsible for the amount shown on their Explanations of Benefits (EOB)Attached are EOB prints related to this issue and the Certificate of CoverageIf you have any questions, please don’t hesitate to contact meSincerely, Christine M***, Sr Appeals Specialist Member Appeals department Fax (216) 687- Attachments
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Medical Mutual has denied my right to access my records where it is stated in my certificate of coverage I should have free and reasonable access to these records upon request These records prove Medical Mutual has broken Ohio consumer protection laws by rescinding their guarantee on the price of medication.I no longer trust Medical Mutual with my health
Regards,
*** ***
July 27, 2017*** ***Revdex.comEuclid Ave., 4th FloorCleveland, Ohio 44115-2408Case ID: *** *** ***Dear Ms***:I am writing in response to your letter dated July 22, Mr*** prescription benefits are administered by *** ***Mr***
states for some reason Medical Mutual has determined he needs to wait weeks or days before he can receive his day supply of Oxycontin 40mg tabletsMr*** believes this is Medical Mutual’s way of telling him to cancel his policy. All schedule II controlled substances are first regulated by federal and state laws governing controlled substancesDispensing of such drugs is at the professional judgment of the Pharmacist at the retail pharmacy locationWe cannot force a pharmacist to dispense a controlled medication early. In this case, Mr*** prescription for Oxycontin is covered for a maximum quantity of tablets within a rolling day periodMeaning a refill can be dispensed once every daysHowever, many Retail pharmacies have policies regarding the dispensing of controlled substances and may further limit at the discretion of dispensing pharmacistMost allow days early. Mr*** filed his prescription on January 4, February 5, March 3, March 31, April 29, May 28, June and July 27, 2017, getting a refill about every daysHowever, on 06/22/17, the *** pharmacy submitted for a Vacation supply override allowing his prescription to fill days earlyThis allowed the June fill to be dispensed before the actual fill date of June This fill despite given early does not impact the next refill date of 07/27/17, as it was understood that by getting the medication days early he still had a days supply from his previous fill making the total days supply available on June at days supply. Medical Mutual and *** *** values Mr*** business and we hope Mr*** continues to be a Medical Mutual Advantage customer. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,Christine M***, Sr Appeals SpecialistMember Appeals departmentFax ***
Dear Ms***:I am writing in response to your letter dated November 23, 2015, regarding services rendered by *** *** *** from 8/1/through 9/19/15. This member has a self-funded group plan through the Ohio Public Employee Retirement SystemIn accordance with the terms
of the contract, whenever a member becomes eligible for Medicare Part B, whether by age or disability, and the member does not sign up for Part B benefits the plan allows Pseudo benefitsThis *** that they calculate the percent difference (Medicare coinsurance) and pay that amount according to contract benefitsIf Medicare Part B would have paid the charges in full, then the services are not eligible for payment under the terms of the contract.The claim denial rational: services that would have been paid in full by Medicare had you been enrolled in Medicare part B coverage are not eligible for payment under the terms of your contractRules from your certificate or summary plan description were used for this determination.Information regarding Medicare eligibility and the plan benefits is included in the member’s Medical Plan Description under IntroductionMedical Mutual administers the benefits in accordance with the plan benefits and limitationsTherefore, the claims have been processed correctly and no benefit is due Attached are the Explanations of Benefits and Certificate of CoverageIf you have any questions, please don’t hesitate to contact me. Sincerely,*** *** ** *** ***Member Appeals departmentFax
April 24, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Patient: *** ***Claim: *** *** ***:I am writing in response to your letter dated April 21, 2015, regarding services rendered to the above patient on
10/26/12, at *** *** ***. The above claim was received on 11/2/At that time our records indicated that Medical Mutual was the only coverage for *** ***The claim was processed and payment for $2,was issued to the provider on 11/5/The Explanation of Benefits (EOB) was issued to the member on 11/6/12.In accordance with the terms of the contract, Medical Mutual does have the right to review claims for up to two (2) years, from the date a claim is initially paidThe member’s Certificate of Coverage under Coordination of Benefits (COB), Proof of Loss states: if the amount of the payments made by Medical Mutual is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid, or any other person or organization that may be responsible for the benefits or services provided for the covered person. In August of 2013, Medical Mutual was notified that *** *** had primary coverage through a Student Plan from 9/1/through 5/1/Therefore, Medical Mutual should have been the secondary payerThe claim was adjusted and denied for a copy of the primary carriers EOBThe original payment was retracted from the provider and a new EOB was issued to the member on 11/13/ Claims must be filed within one (1) year from the date services are renderedPlease refer to How to Apply for Benefits, Proof of Loss in the Certificate that states: Medical Mutual is not legally obligated to reimburse for covered services unless written or electronically submitted proof that covered services have been given to you is receivedProof must be given within days of your receiving covered services or as soon as is reasonably possibleNo proof can be submitted later than one year after services have been received.Claim appeals must be received within days from receipt of the EOBPlease refer to Filing an Appeal, Post Service Claim Appeal that states: you, your authorized representative or your Provider may request a post-service claim appealPost-service claim appeals are those requested for payment or reimbursement of the cost for Medical Care that has already been providedAs with pre-service claims, the post-service claim appeal must be decided within days of the request and must be requested within days of the date you received notice of the denial.According to our records the primary carrier denied the claim for filing limits on 3/10/On 3/20/and 3/24/15, Medical Mutual received written correspondence from the member to consider the claim for paymentThe denial was upheld due to claim filing limits and appeal limitsResponses were issued to the member on 3/31/and 4/6/14. Attached are the EOBs, correspondence files and Certificate of CoverageIf you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax 216.***Attachments
May 14, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Dear Ms***:I am writing in response to your letter dated May 11, 2015, regarding enrollment into Medical Mutual’s Quality and Wellness programs. Medical
Mutual offers a variety of programs that offer education and support to help members achieve their best overall healthThe programs are free and they provide valuable information related to medical conditionsThe programs are voluntary and members do have the option to opt-out. I have contacted our Quality and Wellness departments to ensure Mr*** is removed from the Alere programAn alert has been placed on his file to not enroll him in future programs or mailings. Medical Mutual is very sensitive to privacy issues and we follow all regulations of the Health Insurance Portability and Accountability Act If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Sr Appeals SpecialistMember Appeals departmentFax
August
7,
*** ***
RevDex.com
Euclid Ave., 4th
Floor
Cleveland,
Ohio 44115-
Case
ID: *** *** ***
Dear
Ms***:
I
am writing in response to your letter dated July 31, 2017, andMr
*** additional concerns related to the prescription fill
dates
We
have investigated your concern regarding the actual date your
medication is picked up at the pharmacy. *** pharmacy
confirmed that the date the medication claim is submitted can be
different from the date it is filled or picked up. Although most
prescriptions are filled and picked up on the same date the claim is
submitted this may not always happen. Some pharmacies process
prescription claims in advance of when the customer plans to pick up
the prescriptionThis helps to ensure that the medication will be
ready when promisedUnfortunately, we are only able to record the
date the claim is submitted to us and we do not receive notice of the
pickup dateIf you have further questions about this pharmacy
billing practices please contact *** directly
Thank
you for taking the time to contact usIf you have any questions
regarding this issue, please don’t hesitate to contact me
Sincerely,
Christine
M***, Sr Appeals Specialist
Member
Appeals department
Fax
***
Dear Ms***:I am writing in response to your letter dated June 26, 2015, and the member’s additional commentsThe information provided in the response issued to the Revdex.com on 6/5/15, is true and accurate based on the events that occurred at that time. Medical Mutual’s Payment Recovery department received the copy of the Z*** policy on 6/8/15, after the response was issued to the Revdex.com on 6/5/On 6/17/15, after reviewing the Z*** policy, the Payment Recovery department advised the appropriate department to reprocess claims for primary benefits.The member will be receiving new Explanations of Benefits, for the adjusted claimsIf the member has any questions, he should contact the Customer Care Center number on his identification card for assistance. I apologize for the inconvenience this issue has causedIf you have any questions, please don’t hesitate to contact me. Sincerely,*** Meyers, Sr Appeals SpecialistMember Appeals departmentFax
May
20,
***
***
RevDex.com
Euclid Ave., 4th
Floor
Cleveland,
Ohio 44115-
Case
ID: *** *** ***
Dear
Ms***:
I
am writing in response to your letter dated May 18, 2016, regarding
the member’s additional comments
Prior
to 11/1/15, the member had the SuperDental plan, group number
When a member elects a different dental plan or product, the
group number is changed to reflect the change in benefitsEffective
11/1/15, the member elected the Dental Plan that was assigned group
number
For
the individual products members have to access their Certificate of
Coverage through their My Health Plan (MHP) accountMr*** had
access to his Certificate on 11/1/15, the effective date of the
policyIn accordance with the terms of the contract, Dental PPO
Network Certificate, Examination
Right, it states: this
Certificate can be canceled by returning it by mail or in person,
within days of having it in your possessionAny paid premium will
be fully refundedMedical Mutual did not receive notice to cancel
this plan
Medical
Mutual does not employ brokers or agentsTherefore, Medical Mutual
would not have access to their phone records.
If
you have any questions, please don’t hesitate to contact me
Sincerely,
Christine
M***, Sr Appeals Specialist
Member
Appeals department
Fax
(216) 687-
I am writing in response to your letter dated May 6, 2015, regarding the member’s prescription copayment for Lamictal.For the 2014 benefit period the member had the Off-Exchange Standard Classic 500 Platinum plan. In 2014 the member did pay a lower copayment under this plan for the Brand/Generic...
waiver for Lamictal.Effective 1/1/15, the member elected the On-Exchange Market Classic 1000 Gold plan. When the member elected this plan through the Marketplace they were able to review multiple plans and benefits. The prescription benefits are administered by Express Scripts (ESI). For the home deliver benefit, 90 days supply, the member pays 50 percent of the prescription drug allowed amount, up to a maximum copayment of $1,050.00. ESI does handle waiver requests and ESI does have an approved waiver on file that expires on 10/2/15, at which time the physician must contact ESI for a renewal.I apologize to Mr. [redacted] for the inconvenience this issue has caused. Attached is the Certificate of Coverage. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990Attachment
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
[redacted]
I am not disputing the need to wait extra days for the medicine! I'm stating that the dates they have as the medicine actually being refilled by [redacted] is not the actual date they were filled! For instance: They approval date of May 22ng was not the day [redacted] refilled the prescription! The approval was May 22nd, however, [redacted] had to wait 28 days to refill the refill it being May 25Th! So it was actually filled on May 25th (28 days from the last refill)! This has happened month after month! They need to use the actual pick up date! However, they are using the approval date as the pick up date which is different! An easy call from the insurance company to [redacted] would correct the problem! However, They said time and time again from several Insurance companies employees,"The date of approval is the date that it was picked up"! This date they show as the pick p Date is not the date actually picked up! [redacted] will not allow an early pick up of this meds! Someone needs to fix the communications between the pharmacist and the Insurance Company! Often the pharmacist will get the approval 25 days from last refill or 5 days early! This happens month after month! [redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Their rules state that I am entitled to an appeal for adverse denial of benefits even when they used a rule to deny said benefits. They continue to deny my right to appeal. They will not give me information on how to appeal. They are not following their own rule. I want to pursue a formal appeal which I am entitled to per the same manual they have referenced in their response.
I have the right to appeal. I do not want the company to tell me what the possible outcome of the appeal might be. I want them to give me the information on how to complete the appeal they should allow me to complete the appeal as is their stated policy. I request to exercise my right to appeal no matter what they think the out come may be. As we speak my ulcers have worsened without the needed care. I am looking for a compassionate look at my appeal. This is very urgent now that my ulcers are worse without the need home health care servicesb
I am writing in response to your letter dated May 15, 2015, regarding claim denials related to a work injury that occurred on 6/5/14. This member has retiree coverage through the Ohio Public Employee Retirement System (OPERS). Medical Mutual received claim [redacted] from MetroHealth Medical...
Center for an inpatient admission on 6/5/14, and a benefit of $10,024.54 was issued to the facilityMedical Mutual then received information from an audit that was performed by one of our Vendors at the provider’s facility. Z[redacted] American Insurance Company also received the above claim and they paid $13,875.00 on 11/3/14. It was determined that Z[redacted] was the primary payer for services related to the injury and Medical Mutual is secondary payer and had no liability. The provider agreed that a refund was due to Medical Mutual based on this information. Therefore, Medical Mutual retracted the payment and went forward on any additional recoveries that were related to this claim/injury. Medical Mutual cannot repay any claims until we receive further documentation/denials that individual claims are not related to this injury.Attached is the Certificate of Coverage for the OPERS plan. Please refer to Subrogation/Right of Recovery of Expenses Paid. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted] Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990Attachment
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]
June 3, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]s:I am writing in response to your letter dated May 28, 2015, regarding the member’s Market Classic 1000 Gold policy. When members have an Exchange policy all enrollment information and changes is received from the Marketplace. When Medical Mutual receives a Change in Circumstances from the Marketplace an explanation as to what has changed is not provided. Based on the information received, the member’s account is adjusted accordingly. The member would need to contact the Marketplace for an explanation as to what changed.On 4/21/15, Medical Mutual responded to the member’s email regarding the increase in premiums. The member was advised that his monthly premium was $581.78, $1,399.34 was due, and if the monthly premium is incorrect he would need to contact the Marketplace. On 4/24/15, Medical Mutual received a letter from the member regarding his premiums and requesting a policy cancellation. A response was issued to the member on 5/7/15. As previously stated in our response to the Revdex.com on 5/20/15, the member had a 30 day grace period to pay premiums in full. The member’s grace period started on 4/1/15 and ended on 5/1/15.On 5/7/15, Medical Mutual canceled the policy 3/31/15, since the grace period had ended, the premiums were not paid in full and we had received the member’s request to cancel. On 5/8/15, the Certificate of Creditable Coverage was issued to the member. Attached is the letter from the member and Medical Mutual’s response. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted] Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990
Dear Ms***:I am very disappointed that *** *** Sr Appeals Specialist for Medical Mutual would make a statement that Metrohealth agreed that a refund was dueI received a letter from Metrohealth 05/11/asking me to contract Medical Mutual to advice them that Medical Mutual is the primary insurance and the claim is not a BWC claim(Attached)This letter was faxed to Medical Mutual 05/29/and 06/01/along with copies of Z*** Insurance copolicy (attached) stating they were a secondary insurance and the policy is not a BWC policy.Therefore Medical Mutual and its Vender Auditor made the decision to make it a BWC claim without a BWC claim number or proof that I filed a BWC claimIt is my opinion that Medical Mutual is trying to get out of paying claims simply because a secondary insurance company is involved.My contract with Medical Mutual covers me as a primary insurer regardless of what I am doing and they should pay claims as contracted without inconvenience to my providers that reflects meThere actions has caused a conflict with one of my providers *** *** causing the cancelation of appointments for me and my daughter due to them retracting payments for non BWC claims.In closing they should pay all claims as contracted and contact me in the future if they have questions about a claimAn apology would be appreciated for destroying provider relationships but 'I'm sure that won't happen
Please see the attached response and claim formSincerely, Chris Meyers
Dear Ms***:I am writing in response to your letter dated November 30, 2015, regarding the member’s right to file an appeal in the case of an adverse claim determinationPlease refer to the below section from the member’s Ohio Public Employee Retirement System (OPERS) Medical Plan Description:Introduction, which states: you must enroll in Medicare the first day you become eligibleIf you or any of your eligible dependents are eligible for Medicare but do not enroll, this Plan's coverage for covered hospital (Medicare A) and/or medical (Medicare B) expenses will be reduced by the amount Medicare would have paidThis will be done whether or not you actually enroll in the Medicare program.Helpful Notes, which states: as soon as you are eligible for any type of Medicare, you MUST sign up for it, notify OPERS of your enrollment and use itIf you don't, it will cost you a lot of your own moneyThere are some exceptions, but until you hear otherwise from OPERS, assume this rule is always true.In accordance with the plan benefits, the member does have the right to appeal an adverse claim determinationMedical Mutual is not denying the member their right to appeal. If Medical Mutual had received an appeal, the denial would have been upheld based on the above requirementsIf the member would have been enrolled in Medicare Part B, as required by the Group, Medicare would have paid percent of their Allow Amount for the home visitsTherefore, no benefit would have been due under the OPERS plan. Medical Mutual administers the benefits onlyMedical Mutual is not permitted to change or alter any membership and/or eligibility requirements established by the GroupAttached is the Medical Plan DescriptionIf you have any questions, please don’t hesitate to contact me. Sincerely,*** *** Sr Appeals SpecialistMember Appeals department
In response to your email inquiry dated 7/6/15, the Off-Exchange Standard Classic Platinum plan was not offered for and is currently not available. Sincerely,*** ***Member Appeals department
May 18, *** *** Revdex.com Euclid Ave., 4th Floor Cleveland, Ohio 44115- Case ID: *** *** *** Dear Ms***: I am writing in response to your letter dated May 27, 2016, regarding dental coverage and waiting periods Effective
11/1/15, the member elected the non-group Dental Plan In accordance with the terms of the contract, Dental Benefits, it states: some services may not be covered until an individual has been insured under the plan for a certain period of time, known as a waiting periodRefer to the Schedule of Benefits to determine if any services are subject to a waiting periodThe Schedule of Benefits for Covered Persons Ages and Over shows that Basic Services are subject to a month waiting period and Major Services are subject to a month waiting periodTherefore, the waiting period will not be waived and the member may be held responsible for the amount shown on their Explanations of Benefits (EOB)Attached are EOB prints related to this issue and the Certificate of CoverageIf you have any questions, please don’t hesitate to contact meSincerely, Christine M***, Sr Appeals Specialist Member Appeals department Fax (216) 687- Attachments
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Medical Mutual has denied my right to access my records where it is stated in my certificate of coverage I should have free and reasonable access to these records upon request These records prove Medical Mutual has broken Ohio consumer protection laws by rescinding their guarantee on the price of medication.I no longer trust Medical Mutual with my health
Regards,
*** ***
July 27, 2017*** ***Revdex.comEuclid Ave., 4th FloorCleveland, Ohio 44115-2408Case ID: *** *** ***Dear Ms***:I am writing in response to your letter dated July 22, Mr*** prescription benefits are administered by *** ***Mr***
states for some reason Medical Mutual has determined he needs to wait weeks or days before he can receive his day supply of Oxycontin 40mg tabletsMr*** believes this is Medical Mutual’s way of telling him to cancel his policy. All schedule II controlled substances are first regulated by federal and state laws governing controlled substancesDispensing of such drugs is at the professional judgment of the Pharmacist at the retail pharmacy locationWe cannot force a pharmacist to dispense a controlled medication early. In this case, Mr*** prescription for Oxycontin is covered for a maximum quantity of tablets within a rolling day periodMeaning a refill can be dispensed once every daysHowever, many Retail pharmacies have policies regarding the dispensing of controlled substances and may further limit at the discretion of dispensing pharmacistMost allow days early. Mr*** filed his prescription on January 4, February 5, March 3, March 31, April 29, May 28, June and July 27, 2017, getting a refill about every daysHowever, on 06/22/17, the *** pharmacy submitted for a Vacation supply override allowing his prescription to fill days earlyThis allowed the June fill to be dispensed before the actual fill date of June This fill despite given early does not impact the next refill date of 07/27/17, as it was understood that by getting the medication days early he still had a days supply from his previous fill making the total days supply available on June at days supply. Medical Mutual and *** *** values Mr*** business and we hope Mr*** continues to be a Medical Mutual Advantage customer. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,Christine M***, Sr Appeals SpecialistMember Appeals departmentFax ***
Dear Ms***:I am writing in response to your letter dated November 23, 2015, regarding services rendered by *** *** *** from 8/1/through 9/19/15. This member has a self-funded group plan through the Ohio Public Employee Retirement SystemIn accordance with the terms
of the contract, whenever a member becomes eligible for Medicare Part B, whether by age or disability, and the member does not sign up for Part B benefits the plan allows Pseudo benefitsThis *** that they calculate the percent difference (Medicare coinsurance) and pay that amount according to contract benefitsIf Medicare Part B would have paid the charges in full, then the services are not eligible for payment under the terms of the contract.The claim denial rational: services that would have been paid in full by Medicare had you been enrolled in Medicare part B coverage are not eligible for payment under the terms of your contractRules from your certificate or summary plan description were used for this determination.Information regarding Medicare eligibility and the plan benefits is included in the member’s Medical Plan Description under IntroductionMedical Mutual administers the benefits in accordance with the plan benefits and limitationsTherefore, the claims have been processed correctly and no benefit is due Attached are the Explanations of Benefits and Certificate of CoverageIf you have any questions, please don’t hesitate to contact me. Sincerely,*** *** ** *** ***Member Appeals departmentFax
April 24, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Patient: *** ***Claim: *** *** ***:I am writing in response to your letter dated April 21, 2015, regarding services rendered to the above patient on
10/26/12, at *** *** ***. The above claim was received on 11/2/At that time our records indicated that Medical Mutual was the only coverage for *** ***The claim was processed and payment for $2,was issued to the provider on 11/5/The Explanation of Benefits (EOB) was issued to the member on 11/6/12.In accordance with the terms of the contract, Medical Mutual does have the right to review claims for up to two (2) years, from the date a claim is initially paidThe member’s Certificate of Coverage under Coordination of Benefits (COB), Proof of Loss states: if the amount of the payments made by Medical Mutual is more than it should have paid under this COB provision, it may recover the excess from one or more of the persons it has paid or for whom it has paid, or any other person or organization that may be responsible for the benefits or services provided for the covered person. In August of 2013, Medical Mutual was notified that *** *** had primary coverage through a Student Plan from 9/1/through 5/1/Therefore, Medical Mutual should have been the secondary payerThe claim was adjusted and denied for a copy of the primary carriers EOBThe original payment was retracted from the provider and a new EOB was issued to the member on 11/13/ Claims must be filed within one (1) year from the date services are renderedPlease refer to How to Apply for Benefits, Proof of Loss in the Certificate that states: Medical Mutual is not legally obligated to reimburse for covered services unless written or electronically submitted proof that covered services have been given to you is receivedProof must be given within days of your receiving covered services or as soon as is reasonably possibleNo proof can be submitted later than one year after services have been received.Claim appeals must be received within days from receipt of the EOBPlease refer to Filing an Appeal, Post Service Claim Appeal that states: you, your authorized representative or your Provider may request a post-service claim appealPost-service claim appeals are those requested for payment or reimbursement of the cost for Medical Care that has already been providedAs with pre-service claims, the post-service claim appeal must be decided within days of the request and must be requested within days of the date you received notice of the denial.According to our records the primary carrier denied the claim for filing limits on 3/10/On 3/20/and 3/24/15, Medical Mutual received written correspondence from the member to consider the claim for paymentThe denial was upheld due to claim filing limits and appeal limitsResponses were issued to the member on 3/31/and 4/6/14. Attached are the EOBs, correspondence files and Certificate of CoverageIf you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax 216.***Attachments
May 14, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Dear Ms***:I am writing in response to your letter dated May 11, 2015, regarding enrollment into Medical Mutual’s Quality and Wellness programs. Medical
Mutual offers a variety of programs that offer education and support to help members achieve their best overall healthThe programs are free and they provide valuable information related to medical conditionsThe programs are voluntary and members do have the option to opt-out. I have contacted our Quality and Wellness departments to ensure Mr*** is removed from the Alere programAn alert has been placed on his file to not enroll him in future programs or mailings. Medical Mutual is very sensitive to privacy issues and we follow all regulations of the Health Insurance Portability and Accountability Act If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Sr Appeals SpecialistMember Appeals departmentFax
August
7,
*** ***
RevDex.com
Euclid Ave., 4th
Floor
Cleveland,
Ohio 44115-
Case
ID: *** *** ***
Dear
Ms***:
I
am writing in response to your letter dated July 31, 2017, andMr
*** additional concerns related to the prescription fill
dates
We
have investigated your concern regarding the actual date your
medication is picked up at the pharmacy. *** pharmacy
confirmed that the date the medication claim is submitted can be
different from the date it is filled or picked up. Although most
prescriptions are filled and picked up on the same date the claim is
submitted this may not always happen. Some pharmacies process
prescription claims in advance of when the customer plans to pick up
the prescriptionThis helps to ensure that the medication will be
ready when promisedUnfortunately, we are only able to record the
date the claim is submitted to us and we do not receive notice of the
pickup dateIf you have further questions about this pharmacy
billing practices please contact *** directly
Thank
you for taking the time to contact usIf you have any questions
regarding this issue, please don’t hesitate to contact me
Sincerely,
Christine
M***, Sr Appeals Specialist
Member
Appeals department
Fax
***
Dear Ms***:I am writing in response to your letter dated June 26, 2015, and the member’s additional commentsThe information provided in the response issued to the Revdex.com on 6/5/15, is true and accurate based on the events that occurred at that time. Medical Mutual’s Payment Recovery department received the copy of the Z*** policy on 6/8/15, after the response was issued to the Revdex.com on 6/5/On 6/17/15, after reviewing the Z*** policy, the Payment Recovery department advised the appropriate department to reprocess claims for primary benefits.The member will be receiving new Explanations of Benefits, for the adjusted claimsIf the member has any questions, he should contact the Customer Care Center number on his identification card for assistance. I apologize for the inconvenience this issue has causedIf you have any questions, please don’t hesitate to contact me. Sincerely,*** Meyers, Sr Appeals SpecialistMember Appeals departmentFax
May
20,
***
***
RevDex.com
Euclid Ave., 4th
Floor
Cleveland,
Ohio 44115-
Case
ID: *** *** ***
Dear
Ms***:
I
am writing in response to your letter dated May 18, 2016, regarding
the member’s additional comments
Prior
to 11/1/15, the member had the SuperDental plan, group number
When a member elects a different dental plan or product, the
group number is changed to reflect the change in benefitsEffective
11/1/15, the member elected the Dental Plan that was assigned group
number
For
the individual products members have to access their Certificate of
Coverage through their My Health Plan (MHP) accountMr*** had
access to his Certificate on 11/1/15, the effective date of the
policyIn accordance with the terms of the contract, Dental PPO
Network Certificate, Examination
Right, it states: this
Certificate can be canceled by returning it by mail or in person,
within days of having it in your possessionAny paid premium will
be fully refundedMedical Mutual did not receive notice to cancel
this plan
Medical
Mutual does not employ brokers or agentsTherefore, Medical Mutual
would not have access to their phone records.
If
you have any questions, please don’t hesitate to contact me
Sincerely,
Christine
M***, Sr Appeals Specialist
Member
Appeals department
Fax
(216) 687-
I am writing in response to your letter dated May 6, 2015, regarding the member’s prescription copayment for Lamictal.For the 2014 benefit period the member had the Off-Exchange Standard Classic 500 Platinum plan. In 2014 the member did pay a lower copayment under this plan for the Brand/Generic...
waiver for Lamictal.Effective 1/1/15, the member elected the On-Exchange Market Classic 1000 Gold plan. When the member elected this plan through the Marketplace they were able to review multiple plans and benefits. The prescription benefits are administered by Express Scripts (ESI). For the home deliver benefit, 90 days supply, the member pays 50 percent of the prescription drug allowed amount, up to a maximum copayment of $1,050.00. ESI does handle waiver requests and ESI does have an approved waiver on file that expires on 10/2/15, at which time the physician must contact ESI for a renewal.I apologize to Mr. [redacted] for the inconvenience this issue has caused. Attached is the Certificate of Coverage. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990Attachment
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]
Regards,
[redacted]
I am not disputing the need to wait extra days for the medicine! I'm stating that the dates they have as the medicine actually being refilled by [redacted] is not the actual date they were filled! For instance: They approval date of May 22ng was not the day [redacted] refilled the prescription! The approval was May 22nd, however, [redacted] had to wait 28 days to refill the refill it being May 25Th! So it was actually filled on May 25th (28 days from the last refill)! This has happened month after month! They need to use the actual pick up date! However, they are using the approval date as the pick up date which is different! An easy call from the insurance company to [redacted] would correct the problem! However, They said time and time again from several Insurance companies employees,"The date of approval is the date that it was picked up"! This date they show as the pick p Date is not the date actually picked up! [redacted] will not allow an early pick up of this meds! Someone needs to fix the communications between the pharmacist and the Insurance Company! Often the pharmacist will get the approval 25 days from last refill or 5 days early! This happens month after month! [redacted]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
Regards,
[redacted]
Their rules state that I am entitled to an appeal for adverse denial of benefits even when they used a rule to deny said benefits. They continue to deny my right to appeal. They will not give me information on how to appeal. They are not following their own rule. I want to pursue a formal appeal which I am entitled to per the same manual they have referenced in their response.
I have the right to appeal. I do not want the company to tell me what the possible outcome of the appeal might be. I want them to give me the information on how to complete the appeal they should allow me to complete the appeal as is their stated policy. I request to exercise my right to appeal no matter what they think the out come may be. As we speak my ulcers have worsened without the needed care. I am looking for a compassionate look at my appeal. This is very urgent now that my ulcers are worse without the need home health care servicesb
I am writing in response to your letter dated May 15, 2015, regarding claim denials related to a work injury that occurred on 6/5/14. This member has retiree coverage through the Ohio Public Employee Retirement System (OPERS). Medical Mutual received claim [redacted] from MetroHealth Medical...
Center for an inpatient admission on 6/5/14, and a benefit of $10,024.54 was issued to the facilityMedical Mutual then received information from an audit that was performed by one of our Vendors at the provider’s facility. Z[redacted] American Insurance Company also received the above claim and they paid $13,875.00 on 11/3/14. It was determined that Z[redacted] was the primary payer for services related to the injury and Medical Mutual is secondary payer and had no liability. The provider agreed that a refund was due to Medical Mutual based on this information. Therefore, Medical Mutual retracted the payment and went forward on any additional recoveries that were related to this claim/injury. Medical Mutual cannot repay any claims until we receive further documentation/denials that individual claims are not related to this injury.Attached is the Certificate of Coverage for the OPERS plan. Please refer to Subrogation/Right of Recovery of Expenses Paid. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted] Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990Attachment
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]
June 3, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]s:I am writing in response to your letter dated May 28, 2015, regarding the member’s Market Classic 1000 Gold policy. When members have an Exchange policy all enrollment information and changes is received from the Marketplace. When Medical Mutual receives a Change in Circumstances from the Marketplace an explanation as to what has changed is not provided. Based on the information received, the member’s account is adjusted accordingly. The member would need to contact the Marketplace for an explanation as to what changed.On 4/21/15, Medical Mutual responded to the member’s email regarding the increase in premiums. The member was advised that his monthly premium was $581.78, $1,399.34 was due, and if the monthly premium is incorrect he would need to contact the Marketplace. On 4/24/15, Medical Mutual received a letter from the member regarding his premiums and requesting a policy cancellation. A response was issued to the member on 5/7/15. As previously stated in our response to the Revdex.com on 5/20/15, the member had a 30 day grace period to pay premiums in full. The member’s grace period started on 4/1/15 and ended on 5/1/15.On 5/7/15, Medical Mutual canceled the policy 3/31/15, since the grace period had ended, the premiums were not paid in full and we had received the member’s request to cancel. On 5/8/15, the Certificate of Creditable Coverage was issued to the member. Attached is the letter from the member and Medical Mutual’s response. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted] Sr Appeals SpecialistMember Appeals departmentFax 216.687.7990