Thomas E. Bayliff Funeral Home Inc.

Please see the attached response and related documents. Sincerely, [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 10617360, and find that this resolution is partially satisfactory to me.  It does fail to address the issue that the have not provided the privacy forms via mail as directed nor addressed that their own paperwork states they can refuse to follow the directives provided by the customers. I will wait to see if the forms are ever sent. If not, I will return and file my complaint again.
Regards,
[redacted]

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.
Thee is no explanation as to what the "chane in circumstances" were, but some vague term.  When I sent letters to Medical Mutual they did not respond.   When I called I was hung up on.  I just received bills and no explanation as to why my insurance keeps going up for no reason.
I need insurance as I have cancer and high blood pressure.  Why is this so hard to get done????
[redacted]

This business response was received by Revdex.com staff member ** via voicemail.Chris M states she is awaiting the results of a customer review being conducted to look into the customer's issues.Chris said she will submit a response once the review results are available to her, hopefully 12/20/17.

May 7, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Plan Type: Self-Funded Group CoverageGroup: [redacted]:I am writing in response to your letter dated May 3, 2015, regarding the member’s...

request for a $39.47 refund. On 3/4/15, [redacted] contacted Medical Mutual regarding the payment she issued to Medical Mutual in error. The member was advised that this issue would have to be researched before a refund could be issued. There was a delay in locating the payment, since the member did not owe Medical Mutual any funds. On 4/15/15, a refund for $39.47 was issued to the member. A Customer Care Specialist also contacted the member to provide this information. On 5/2/15, the member contacted Medical Mutual and advised that she had not received her refund. It was determined that the payment had been issued to [redacted] in error. Our Finance Department is in the process of reissuing a manual check to [redacted], which is the address on the last Application and Change form received from the member on 8/28/13, and on our membership files. In reviewing the member’s complaint, it was noted that the member shows her address as [redacted]. If the address Medical Mutual currently has on file is incorrect, the member should contact the Customer Care Center at the number show in her Identification Card for assistance. Once the refund has been released, I will notify the Revdex.com. If you have any questions regarding this issue, please don’t hesitate to contact me.  Sincerely,[redacted] Appeal Specialist IIMember Appeals departmentFax 216.[redacted]

May 21, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Claims: [redacted]Provider: Emergency Physicians, [redacted]Date of Service: 8/31/14[redacted]I am writing in response to your letter dated May...

19, 2015, regarding the partial denial of emergency room services.   The use of the emergency room and the emergency room physician charges were denied. The denial rational: under the terms of this contract, emergency room charges that do not meet medical emergency or accident emergency criteria are not eligible for coverage.On 10/24/14, Medical Mutual received the provider’s first level of appeal. Upon review it was determined that the medical record information submitted does not indicate that this treatment was related to a medical emergency. Therefore, this claim has been processed based on the non-emergency provisions of your contract. A response was issued to the provider on 12/5/14. On 1/27/15, Medical Mutual received the member’s request for an internal level of appeal. Upon review it was determined the service provided was not considered a valid use of the emergency room under the prudent layperson definition. The patient presented with back pain. No acute weakness or loss of sphincter control. Services were appropriate for a doctor’s office. Therefore, the level of benefit was upheld. On 2/23/15, a response was issued to the member, with included her additional rights for review. Attached are the Explanations of Benefits, Certificate of Coverage and the letters issued to the member and provider. If you have any questions regarding this issue, please don’t hesitate to contact me.  Sincerely,[redacted], Sr Appeals SpecialistMember Appeals departmentFax 216.[redacted]Attachments

[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 [redacted], and find that this resolution...

is satisfactory to me.  Please thank them for honoring the insurance policy, and thank you for giving us a means to obtain resolution to these types of issues.
Regards,
[redacted]

May 20, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]:I am writing in response to your letter dated May 14, 2015, regarding the member’s Market Classic 1000 Gold policy. On 12/19/14, Medical Mutual...

received the re-enrollment from the Exchange to be effective 1/1/15. The monthly premium cost, including Federally Mandated Fees, is $581.78. The member received a monthly subsidy of $236.00 and the member’s monthly premium cost was $345.78. Please see below:12/24/14, member billed for the January 2015 premium.1/19/15, member billed for the February 2015 premium.2/16/15, member billed for the March 2015 premium.On 2/28/15, Medical Mutual received a Change in Circumstances from the Exchange showing the member no longer qualified for a subsidy allowance effective 3/1/15. Therefore, the member was responsible for the full monthly premium cost of $581.78. The balance due for March was billed to the member on 3/16/15, along with the premium due for April. In accordance with the terms of the contract, the required premiums must be paid in advance or within a grace period of 31 days after the due date. If we do not receive the premium within the grace period, the coverage will end effective on the due date for which the required premium was not received. Medical Mutual did not receive the required premium due by the end of the grace period and the policy was cancelled effective 3/31/15. Attached are the 2015 premium invoices, documents from the Exchange and 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.[redacted]Attachments

Please see the attached response and related documents. Sincerely, Chris M[redacted]

Dear Ms. [redacted]: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 determination. Please 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 eligible. If 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 paid. This 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 it. If you don't, it will cost you a lot of your own money. There 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 determination. Medical 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 requirements. If the member would have been enrolled in Medicare Part B, as required by the Group, Medicare would have paid 100 percent of their Allow Amount for the home visits. Therefore, no benefit would have been due under the OPERS plan. Medical Mutual administers the benefits only. Medical Mutual is not permitted to change or alter any membership and/or eligibility requirements established by the Group. Attached is the Medical Plan Description. If you have any questions, please don’t hesitate to contact me.  Sincerely,[redacted], Sr Appeals SpecialistMember Appeals departmentAttachment

October 4, 2017 [redacted]Revdex.com2800 Euclid Ave., 4th FloorCleveland, Ohio 44115-2408Case ID: [redacted]Type of Service: MedicalPolicy Effective Date: 2/1/17Dear Ms. [redacted]:I am writing in response to your letter dated September 13, 2017. Ms. [redacted] states she...

wanted to be enrolled into the [redacted] plan since this plan has all of her providers listed as participating. Ms. [redacted] also states she went to her eye doctor and was informed that they were not part of her plan. Ms. [redacted]’s concern is that none of her physicians are covered under her current plan and out-of-network services are not covered.For 2017 Ms. [redacted] has the [redacted] policy. This HMO Plan services covered persons who reside in the counties of Athens, Delaware, Fairfield, Franklin, Hardin, Licking, Marion, Morrow, Pickaway, Richland and Union in the State of Ohio. This is known as the "Service Area."   In accordance with the plan coverage, in order to receive benefits the member must use the services of a healthcare professional or facility within the [redacted]. Benefits will not be reduced if the member goes to a Non-HMO Network Provider in a Medical Emergency. I reviewed Ms. [redacted]’s 2017 claims history and services were rendered within the [redacted] network. Ms. [redacted] has received the highest level of benefits available for all claims. Regarding vision services, this plan only covers Pediatric Vision Services for covered persons under age 19. I do apologize to Ms. [redacted] for the confusion between the HMO Network names. It would not be beneficial to Ms. [redacted]’s to cancel hear coverage this late into the year. Ms. [redacted] will be eligible to change plans during the 2018 open enrollment period. Thank you for taking the time to contact us. Attached is Ms. [redacted]’s current Certificate of Coverage. If you have any questions, please don’t hesitate to contact me.  Sincerely,Christine M[redacted], Sr Appeals SpecialistMember Appeals departmentFax [redacted]Attachment