May 7, [redacted] ***Revdex.comEast 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 $refundOn 3/4/15, [redacted] contacted Medical Mutual regarding the payment she issued to Medical Mutual in errorThe member was advised that this issue would have to be researched before a refund could be issuedThere was a delay in locating the payment, since the member did not owe Medical Mutual any fundsOn 4/15/15, a refund for $was issued to the memberA Customer Care Specialist also contacted the member to provide this informationOn 5/2/15, the member contacted Medical Mutual and advised that she had not received her refundIt was determined that the payment had been issued to [redacted] in errorOur 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 filesIn 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 assistanceOnce the refund has been released, I will notify the Revdex.comIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] Appeal Specialist IIMember Appeals departmentFax [redacted]
May 21, [redacted] ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] ***Claims: [redacted] Provider: Emergency Physicians, [redacted] Date of Service: 8/31/[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 deniedThe 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 appealUpon review it was determined that the medical record information submitted does not indicate that this treatment was related to a medical emergencyTherefore, this claim has been processed based on the non-emergency provisions of your contractA response was issued to the provider on 12/5/On 1/27/15, Medical Mutual received the member’s request for an internal level of appealUpon review it was determined the service provided was not considered a valid use of the emergency room under the prudent layperson definitionThe patient presented with back painNo acute weakness or loss of sphincter controlServices were appropriate for a doctor’s officeTherefore, the level of benefit was upheldOn 2/23/15, a response was issued to the member, with included her additional rights for reviewAttached are the Explanations of Benefits, Certificate of Coverage and the letters issued to the member and providerIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Sr Appeals SpecialistMember Appeals departmentFax [redacted] Attachments
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 days to refill the refill it being May 25Th! So it was actually filled on May 25th (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 days from last refill or days early! This happens month after month! [redacted]
October 4, [redacted] ***Revdex.comEuclid Ave., 4th FloorCleveland, Ohio 44115-2408Case ID: [redacted] Type of Service: MedicalPolicy Effective Date: 2/1/17Dear Ms***:I am writing in response to your letter dated September 13, Ms [redacted] states she wanted to be enrolled into the [redacted] plan since this plan has all of her providers listed as participatingMs [redacted] also states she went to her eye doctor and was informed that they were not part of her planMs [redacted] ’s concern is that none of her physicians are covered under her current plan and out-of-network services are not covered.For Ms [redacted] has the [redacted] policyThis 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 OhioThis 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 EmergencyI reviewed Ms [redacted] ’s claims history and services were rendered within the [redacted] networkMs [redacted] has received the highest level of benefits available for all claimsRegarding vision services, this plan only covers Pediatric Vision Services for covered persons under age I do apologize to Ms [redacted] for the confusion between the HMO Network namesIt would not be beneficial to Ms [redacted] ’s to cancel hear coverage this late into the yearMs [redacted] will be eligible to change plans during the open enrollment periodThank you for taking the time to contact usAttached is Ms [redacted] ’s current Certificate of CoverageIf you have any questions, please don’t hesitate to contact me Sincerely,Christine M***, Sr Appeals SpecialistMember Appeals departmentFax [redacted] Attachment
[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 customersI will wait to see if the forms are ever sentIf not, I will return and file my complaint again Regards, [redacted]
May 7, [redacted] ***Revdex.comEast 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 $refundOn 3/4/15, [redacted] contacted Medical Mutual regarding the payment she issued to Medical Mutual in errorThe member was advised that this issue would have to be researched before a refund could be issuedThere was a delay in locating the payment, since the member did not owe Medical Mutual any fundsOn 4/15/15, a refund for $was issued to the memberA Customer Care Specialist also contacted the member to provide this informationOn 5/2/15, the member contacted Medical Mutual and advised that she had not received her refundIt was determined that the payment had been issued to [redacted] in errorOur 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 filesIn 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 assistanceOnce the refund has been released, I will notify the Revdex.comIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] Appeal Specialist IIMember Appeals departmentFax [redacted]
May 21, [redacted] ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] ***Claims: [redacted] Provider: Emergency Physicians, [redacted] Date of Service: 8/31/[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 deniedThe 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 appealUpon review it was determined that the medical record information submitted does not indicate that this treatment was related to a medical emergencyTherefore, this claim has been processed based on the non-emergency provisions of your contractA response was issued to the provider on 12/5/On 1/27/15, Medical Mutual received the member’s request for an internal level of appealUpon review it was determined the service provided was not considered a valid use of the emergency room under the prudent layperson definitionThe patient presented with back painNo acute weakness or loss of sphincter controlServices were appropriate for a doctor’s officeTherefore, the level of benefit was upheldOn 2/23/15, a response was issued to the member, with included her additional rights for reviewAttached are the Explanations of Benefits, Certificate of Coverage and the letters issued to the member and providerIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Sr Appeals SpecialistMember Appeals departmentFax [redacted] Attachments
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 days to refill the refill it being May 25Th! So it was actually filled on May 25th (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 days from last refill or days early! This happens month after month! [redacted]
October 4, [redacted] ***Revdex.comEuclid Ave., 4th FloorCleveland, Ohio 44115-2408Case ID: [redacted] Type of Service: MedicalPolicy Effective Date: 2/1/17Dear Ms***:I am writing in response to your letter dated September 13, Ms [redacted] states she wanted to be enrolled into the [redacted] plan since this plan has all of her providers listed as participatingMs [redacted] also states she went to her eye doctor and was informed that they were not part of her planMs [redacted] ’s concern is that none of her physicians are covered under her current plan and out-of-network services are not covered.For Ms [redacted] has the [redacted] policyThis 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 OhioThis 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 EmergencyI reviewed Ms [redacted] ’s claims history and services were rendered within the [redacted] networkMs [redacted] has received the highest level of benefits available for all claimsRegarding vision services, this plan only covers Pediatric Vision Services for covered persons under age I do apologize to Ms [redacted] for the confusion between the HMO Network namesIt would not be beneficial to Ms [redacted] ’s to cancel hear coverage this late into the yearMs [redacted] will be eligible to change plans during the open enrollment periodThank you for taking the time to contact usAttached is Ms [redacted] ’s current Certificate of CoverageIf you have any questions, please don’t hesitate to contact me Sincerely,Christine M***, Sr Appeals SpecialistMember Appeals departmentFax [redacted] Attachment
Please see the attached response and related documentsSincerely, Chris M***
[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 customersI will wait to see if the forms are ever sentIf not, I will return and file my complaint again Regards, [redacted]