March
2, Dear *** ***,I am responding to your e-mail received on February 27,
2015, concerning *** ***’s complaint about his claims and how to file an
appealWe have not received federally required HIPAA
authorization from the complainant to release
protected health information
concerning this accountTherefore, we can only provide a general response to
this complaintThis group plan is offered by the U.SOffice Personnel of
Management (OPM)United Concordia Life and Health Insurance administers and
underwrites FEDVIP for OPMAs a Federal plan, FEDVIP is not subject to state
insurance laws.Benefit booklets for FEDVIP members were provided
advising alternate benefit provisions and how to file an appeal. The alternate benefit provision determines how payment is
made when there are two or more clinically acceptable dental services available
to satisfactorily correct the same dental conditionThis provision states that
United Concordia provides coverage for the less expensive service available,
while still ensuring that you receive the quality care you needShould the
member and the dentist choose the more expensive treatment, the member is
responsible for the additional charges beyond the allowance for the alternate
service, even if an in-network providerThis information can be found on page
of the benefit booklet provided to our FEDVIP members.If a FEDVIP member is looking to file an appeal, the
disputed claims process must be followedThe FEDVIP law does not provide a
role for the Office Personnel of Management (OPM) to review disputed claims
The process on how to dispute a claims decision is found on page of the
FEDVIP benefit booklet and outlines the steps that the member would take.Based on the member’s intent to submit an appeal, an
appeal has been submitted on his behalf. *** *** will receive a response once a
determination is made.If *** *** has any additional questions, he may
contact FEDVIP dedicated customer service at ###-###-####.Sincerely,Kayleigh M. Specialized Services Representative
April 18, Dear ***:I am writing in response to your letter dated April 16, 2014, concerning claims for the *** familyWe received this letter on April 16, 2014.The ***’s have a PPO group dental plan through * *** Medical ***This is a self insured
plan and United Concordia provides administrative services only.In the letter, *** provided a listing of service dates for each member of the family that she believes were not processed correctly by United ConcordiaThe following represents our findings:*** ***:Date of Service:September 17, Claim Number: *** Total Charges: $Amount Paid: $153.00*** is responsible for non-covered services which are listed on the Dental Explanation of Benefits statement dated October 3, 2013, which is enclosed.Date of Service:September 25, Claim Number: *** Total Charges: $Amount Paid: 220.15*** is responsible for the provider’s charges less any amount paid for the restorations and deductibleThese amounts are listed on the Dental Explanation of Benefits statement dated October 10, 2103, which is enclosed.*** ***Date of Service:November 29, Claim Number: *** Total Charges: $Amount Paid: $192.00*** is responsible for the non-covered fluoride onlyA copy of the Dental Explanation of Benefits is enclosed.Date of Service:December 4, Claim Number: *** Total Charges: $Amount Paid: $71.00Charges for the scaling and planing + teeth were not considered because x-rays and periodontal charting were not sent by ***It is ***’s responsibility to provide this information so the claim can be reconsideredA Dental Explanation of Benefits statement dated December 6, 2012, is enclosed.Date of Service:April 29, 2013Claim Number: *** Total Charges: $Amount Paid: $41.25*** is responsible for deductible, coinsurance and the service not paid because of frequencyA Dental Explanation of Benefits statement dated May 9, 2013, is enclosed.Date of Service:December and 6, Claim Number: *** Total Charges: $Amount Paid: $ 0No payment was made for these services because the x-rays and periodontal charting were not sent by ***A Dental Explanation of Benefits statement dated June 20, is enclosed.Date of Service:June 11, 2013Claim Number: *** Total Charges: $Amount Paid: $ 0No payment was made because the x-rays were not sufficient to determine eligibility for the servicesA Dental Explanation of Benefits statement dated October 10, 2013, is enclosed.*** ***Date of Service:January 22, Claim Number: *** Total Charges: $Amount Paid: $42.40The member is responsible for coinsurance amountsA Dental Explanation of Benefits statement dated March 21, 2013, is enclosed.Date of Service:July 23,2013Claim Number: *** Total Charges: $Amount Paid: $122.40The member is responsible for coinsurance amountsA Dental Explanation of Benefits statement dated August 15, 2013, is enclosed.*** ***Date of Service:October 1,Claim Number: *** Total Charges: $Amount Paid: $132.00The member is responsible for the non-covered service and the unpaid service due to frequencyA Dental Explanation of Benefits statement dated October 3, 2013, is enclosed.Date of Service:February 18,Claim Number: *** Total Charges: $Amount Paid: $80.00Member is responsible for the fluorideA Dental Explanation of Benefits statement dated February 20, 2014, is enclosed.Date of Service:February 18, Claim Number: *** Total Charges: $Amount Paid: $ 0This claim was reviewed by two Dentist Advisor’s and both determined that payment is not eligible for the services reportedDental Explanations of Benefits statements dated March 27, 2014, and April 10, 2014, are enclosed.If I may be of further assistance, please feel free to contact me directly.Sincerely,
July 15, Dear ***:I am writing in response to your letter dated July 10, 2014, concerning dental coverage for *** ***We received this letter on July 10, 2014.*** is covered as a subscriber under the Individual Dental ProgramThe effective date
of coverage was March 1, 2014, under group number MPAThe situs of this fully insured plan is in Pennsylvania.*** expressed concern that her account was drafted to cover her premium and as a result, she received charges from her bank for an overdraftIn addition, *** wishes to cancel her Individual Dental Plan and receive a full refund.Our records show that the automatic draft of ***’s account was to occur on the 25th of each monthThis is the typical arrangement made when members opt to have funds automatically withdrawn from their account*** reported this created an overdraft on her account and her bank charged her $We received ***’s fax showing the overdraft charge on June 13, A refund check was mailed in this same amount to *** on June 26, 2014.Based on ***’s request, we have requested that her contract be cancelled as “never in force”Currently our records show that a reversed payment was issued back to her account in the amount of $on May 30,A refund in the amount of $will be processed and sent to *** in the near future.If I may be of further assistance, please feel free to contact me directly.Sincerely,
January 6, Dear *** ***:
I am responding to your e mail that was received on December 31, 2014, concerning orthodontic treatment payments.We have not received federally required HIPAA authorization from the complainant to release protected health information
concerning this accountTherefore, we can only provide a general response to this complaint.Under this contract/systematic orthodontic treatment payments are made over the length of treatmentWhen this complaint was received, I called the provider and obtained the treatment completion dateThey confirmed that the subscriber paid item the balance dueWe will pay the subscriber our remaining treatment balance on January 8, 2015.I have enclosed a HIPAA authorization form to complete and return with the subscriber's signature if you need additional information, if *** *** has additjonal questions concerning his plan, he may call Dental Customer Service at ###-###-####.Sincerely, Marta M
Specialized Service Unit
June 29, Dear *** ***:
I am writing in response to a your email that was accessed on June 23, 2015, concerning a preauthorization claim for a crown on Tooth Number by *** ** ***, DMD*** *** is covered as the member under a Dental PPO group plan
through *** *** ***The effective date of coverage was September 1, 2014, under group number ***The situs of the fully insured plan is in Pennsylvania.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim formUnited Concordia dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibility.A Dentist Advisor then reviews the case by studying claims history, reports, correspondence, and diagnostic informationFollowing the review, the claim is processed based on the Dentist Advisor’s opinion and the subscriber’s contractA provider may submit a request for a second review to our Dentist Advisor Unit disputing an advisor denialIf upheld, the provider or subscriber may request an appeal within days from receiptCrown and Onlay approval is based on submitted documentationThe tooth must include at minimum a periapical radiograph, demonstrate a significant loss of tooth structure that the tooth cannot be adequately restored using a direct restoration such as an amalgam or composite; must demonstrate no significant bone loss and the periodontal condition is adequate with no evidence that periodontal treatment is needed and has no periapical pathologyIf a root canal was performed, the radiograph must show the entire apices and demonstrate that the root canal meets acceptable standards of careOn February 13, 2015, we received a preauthorization claim, number *** for a surface porcelain onlay on Tooth Number for *** ***On March 3, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated March 5, 2015.On March 26, 2015, we received a preauthorization claim, number *** *** for a surface resin (white) posterior restoration on Tooth Number for *** ***The service was approved allowing $minus $deductible leaving $payable at percent or a $payment and member’s liability $($deductible and $coinsurance)This was explained on the Explanation of Benefits statement that was sent to *** *** and *** dated March 26, On April 17, 2015, we received a preauthorization claim, number *** for a porcelain ceramic crown on Tooth Number for *** ***On May 6, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (white filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated May 7, On May 21, 2015, we received a call from *** regarding the denial for a crown on Tooth Number We explained how a second review could be requested and at that time the provider can also request a call from the Dentist Advisor during the second reviewOn May 21, 2015, *** called back and asked us to explain how to request a second review to the providerThe representative called the dental office and per ***’s request allowed provider to fax information to representativeThis information was received on May 22, 2015, and forwarded to our Dentist Advisor for a second review (Inquiry Number ***)On May 22, 2015, our Dentist Advisor, MTA***, DDS, performed an independent review and spoke to provider (*** ***) and explained that due to no extensive breakdown, crowns and onlays are not covered to prevent fractures in the futureThis was also explained on the Explanation of Benefits statement dated May 28, *** *** is a participating provider and these denials are not billable to the patient unless *** signed a statement agreeing to pay for the services if they were not approved by her insuranceIf you have any questions, please call Dental Customer Service at ###-###-####Sincerely
Deb RSpecialized Services Representative
--------- Forwarded message ----------From:
"">Revdex.com of Metro Washington DC Date: Wed, Sep 3, at 10:AMSubject: Fwd: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #***.To: *** ***
---------- Forwarded message ----------
From: ***>
Date: Tue, Sep 2, at 6:PM
Subject: Re: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #***
To: [email protected]
I did get a letter from them today saying they are going to pay the dental claim
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:
A "Dental Advisor" decides if a procedure qualifies for coverage, rather than the attending dentist. There is no recourse beyond the appeals process besides "civil litigation." Therefore, any procedure may be rejected at United Concordia's whim, without realistic consumer recourse.
2. I was informed by a customer service representive on 4/(she called me) that United Concordia "sets the bar high" when deciding what will be covered. With regard to periodontal scaling, the company requires the dentist to provide an exceptional amount of documentation as evidenced by this statement:
Procedure RejectedPeriodontal scaling and root planing requires review by a
Dentist AdvisorIn order for the service(s) to be considered, please submit
full mouth duplicate radiograph or digital images and complete periodontal
chartingA complete and compliant or ADA claim form must be submitted
with the requested documentation.Procedure Rejected
With regard to radiographs:
Procedure RejectedPeriapical radiographs performed on the same date as a
periodic oral evaluation requires review by a Dentist AdvisorIn order for the
service(s) to be considered, please submit a copy of the periapical
radiograph(s) or digital images and an explanation of the patient's specific
signs and symptomsA complete and compliant or ADA claim form must be
submitted with the requested documentation.Procedure Rejected
3. United Concordia failed to respond to multiple requests for pre-authorization of work in late 2013/early for family member D. They claim they never received the multiple requests (per phone discussion with "***" on 4/7/14), despite documentation from the dentist showing otherwise. The service was ultimately performed and denied as unnecessary. As an aside, *** also informed me that he speaks with customers who are experiencing similar difficulties with United Concordia "all day long."
Regards,
***
---------- Forwarded message ----------
From: *** ***
Date: Wed, Apr 9, at 11:AM
Subject: complaint #***
To: [email protected]
I just sent a message to them through their contact us form, since they have yet to provide me with a direct email address and I am working the same hours they are so calling and waiting on hold is not really feasible
I explained in my message to them that I did finally receive the refund checkThey sent it to wrong address, my physical instead of my mailing, I live on a nature preserve where there is no way a mailman could even get his little car up my road
The post office was kind enough to call and let me know they had the check and I could pick it up or they could return to sender
I called United Concordia and spoke with a gentleman, explaining that I was worried the check wasn't good anymore and whether I should wait for them to issue a new oneHe told me the check was fine and to go ahead and deposit itThat I would only need to call them back if there was an issue when I deposited it
I deposited it the next day, which was last weekYesterday, the 8th, my bank notified me that a stop payment had been put on the check, the money was taken out and I was charged a $fee for the returned check and a $fee for having to pull money out of my savings to cover it.
I explained to United Concordia my bank is now sending me back the bad check and that a new check will need to be issued that now includes the $in fees I accrued at their fault, making it a total of $
I have asked them to send it to my work address, which I provided and I am awaiting response
Thank you,
*** ***
I am writing in response to your letter dated March 10, 2015, concerning a claim for a buildup and crown for *** *** completed on May 14, We received this letter on March 10, Ms*** was covered as a subscriber under a PPO group plan through NC Flex High OptionThe
effective date was June 1, 2013, under group number ***Her coverage terminated on February 1, The situs of this fully insured plan was in North Carolina.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim formUnited Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine United Concordia’s financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibilityUnited Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographsFollowing the review, the claim is processed based on the Advisor’s opinion and the subscriber’s contractOn May 22, 2014, we received claim number *** from Dr*** *** for a buildup and crown on Tooth Number Our Dentist Advisor reviewed the information and determined that no payment can be madeThe Dentist Advisor indicated that the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for a buildupNotice was sent to the provider and member on July 24, On August 11, 2014, we received a request for a second review of the buildup and crown on Tooth Number Our Dentist Advisor reviewed the information provided and determined that no payment can be made because the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for the buildupNotice was sent to the provider and member on October 9, On October 22, 2014, we received a request for an appeal of the buildup and crown on Tooth Number Our Dentist Advisor reviewed the information provided and determined that no payment can be madeThe Dentist Advisor states that the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for a buildupA letter was sent dated November 4, 2014, and an Explanation of Dental Benefits statement dated November 6, was issued to both Ms*** and Dr***Although it is not required, a predetermination is suggestedThis is submitted prior to the services being performed and is reviewed by a Dentist Advisor to determine eligibility and coverage for the proposed services.Since Dr*** is not a participating provider, Ms*** is responsible for the charges for these non-covered servicesIf I may be of further assistance, please feel free to contact me directlySincerely,
Lisa AR***
Specialized Services Representative
###-###-####
March 21, I am writing in response to a complaint that was posted on March 11, 2014, by *** *** regarding her not receiving account information in order to schedule her daughter’s dental appointments, as well as being unable to create an online accountWe received your email
on March 14, 2014.Our research reveals that we received ***’s application for the I-Dental individual plan on February 22, *** was sent an email on February 22, 2014, to inform her that the application had been approvedOn February 25, 2014, we sent an email to *** informing her that her bill was ready to be viewed.There is no record of *** calling either United Concordia’s Customer Service department or the Billing and Enrollment departmentThe email address that’s posted on ***’s file is *** and there are no emails in our mailbox or the archives from this addressOur clerical department also posts emails and images they receive from a member’s caseNo logs of this kind are posted on ***’s file.Due to the unfortunate circumstances *** experienced, we have terminated her case, *** and requested an expedited refund of $This was requested on March 17, 2014, and expedited refunds usually take three to five business days to process.If I may be of further assistance, please contact me.Sincerely
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:
United Concordia should not have turned me over to collections in the first place I called them multiple times requesting I be removed from collections, which they assured me I had been According to the collections agency I am still in collections The last time I called United Concordia about it I was told that because they couldn't know which agency they turned my case over to I would have to contact the collections agency directly which I have now had to do multiple times They told me to tell the collections agency that United Concordia said I didn't owe them any money As ludicrous as that sounds I did it anyway because I don't want this to affect my credit
The collections agency laughed when I told them that and said that was not how it worked They told me I was still on their collections list They could not tell me if this continuing and unfortunate situation affected my credit rating so as a result I have had to and will have to continue to pull my credit report
United Concordia's abysmal customer service and unethical business practices has taken a great deal of time out of my life Had they processed my payments on time initially or handled the situation properly at any point subsequently, none of this would be happening
Regards,
*** ***
March 9, 2015Dear *** ***:I am responding to your email received on March 2, 2015, concerning dental services provided on December 4, 2014, and January 21, 2015, by *** *** *** *** *** of Pottstown, Pennsylvania.We have not received federally required HIPAA
authorization from the complainant to release protected health information concerning this accountTherefore, we can only provide a general response to the information you provided in this complaint.*** *** is enrolled as the subscriber under an *** *** *** (***) Dental Health Maintenance Organization (DHMO) *** *** *** dental plan that is administered by United Concordia.This DHMO plan requires services to be provided by the patient's assigned, participating, Primary Dental Office (PDO)When *** *** requested a PDO change on December 4, 2014, *** was unable to make this change to this provider's non-participating Pottsville, Pennsylvania location where these services were provided*** *** *** *** *** does participate in Collegeville, Pennsylvania, which is located within less than ten miles from the subscriber's home zip codeOn March 12, 2015, we will pay the provider as an exception for services provided on January 21, 2015, as if they were provided by her assigned PDOWe will do the same for services provided on December 5, 2014, if we receive that claim, which we requested twice from her provider.| called *** *** on March 4, 2015, and explained thisShe called me back on March 9, 2015,and states she does not want to change her PDO at this time because they do not bill her all the co-pays she would oweShe will fax me a claim for the services provided December 5, 2014.If you need additional information concerning these services, I have enclosed a HIPAA authorization form for you to return to us after it is completed and signed by the subscriber.If MsFritz has additional questions concerning these services, she may call me at the number provided her, or she may call Blue Extra Dental Customer Service at ###-###-####If you have any questions concerning the release of protected health information, please call our Privacy Department at ###-###-####.Sincerely,Marta M
SrService Representative Dental Customer Service Specialized Service Unit
Dear *** ***:
I apologize that you have been experiencing these many difficulties when trying to get your reimbursement However, please be aware that we are making every effort possible to assist you with your efforts
Yes, you may scan and email the documents to: ***
*** *** has informed me that when he receives the information, he will take care of it right away
Thanks
*** ***
[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 [redacted], and find that this resolution is satisfactory to me.
Regards,
[redacted]
Dear [redacted],
The phone calls are recorded - as stated by the message on tape when you call for help or questions. I urge you to ask for the tape of my conversation with Ms. M[redacted] regarding this problem. At NO TIME did Ms. M[redacted] mention anything regarding a co pay was to be paid by me for the bill. The words co-pay never even came up when I spoke about Ms. M[redacted] covering the bill. Yes, we did have a conversation about changing offices, which Ms. M[redacted] THEN STATED that a $45 fee would be due if I selected a nearby office. I told her that I never paid a $45.00 fee when I went to University of [redacted] and I had went there for over a year. We laughed and said that it was worth the drive and the lack of problems with billing to go to U of *. Never at any time did Ms. M[redacted] instruct me that the $90 was due - as she told me "as an exception we will cover this bill".
I am tired of this going back and forth - I will accept what ever is determined. I just hope that the phone call of our recorded phone call can be obtained before a final decision is made.
Thank You for all your help,
[redacted]
October 21, 2014Dear [redacted]:I am writing in response to your letter dated October 17, 2014, concerning [redacted]. We received this letter on October 17, 2014.As indicated previously, we contacted the premium center and confirmed [redacted] is not in a collection status with United Concordia. It may take several weeks for [redacted]’s files to be cleared by the collection agency. Unfortunately, we cannot control the speed at which this agency handles their files.If we may be of further assistance, please feel free to contact Dental Customer Service at: ###-###-####.Sincerely,
Lisa RSpecialized Services Representative
Complaint: [redacted]
I am rejecting this response because:I want United Concordia to finally pay what they owe for a procedure I had done in December 2013. This company has shown a clear pattern of avoidance of payment. They have spent so much of my time and my dentist’s and kept asking for more evidence, information to be filed on different forms, that my dentist has threatened to report them to the Ohio Department of Insurance. I hope that he does. They have created so many hoops to jump through, and made the process as difficult as possible, clearly avoid paying for a simple crown. Nothing we send them is good enough, and they make the process as difficult as they can. Just one example of many; they will not accept FAXed information from my dentist. Everyone and their brother has a FAX machine, and can send and receive FAXes. They are built into even inexpensive printers. A large part of this company’s business is (or should be) communicating with their customers. Yet, when my dentist wanted to FAX them information, when they said they had not received the 2 claims they had sent by mail, a UC rep, said “We WILL NOT accept FAXed information”. How is this good in any way for the clients and providers who try to send them information? It does however make the process of getting claims processed more slow and difficult, which would result in more money for the insurance company; they can keep the money in their bank account longer earning interest and making the process more difficult will mean that more people give up on getting their claims paid, which equals more money in the insurance company’s ‘pockets. As we come up on almost of year of haggling with United Concordia, my Dentist has told me that he met their latest demands back in June, sent what they asked for this time - a different X-ray than the first one he sent, and a narrative of what was done and why. So, I get an explanation of benefits from United Concordia dated August, again denying payment, which vaguely states “additional information was required to process these services. The provider should resubmit these services….” This is the most evasive, slippery, unethical insurance company I have ever dealt with.Quit giving myself and the dental provider the run around, and putting up hurdles to payment, and pay this legitimate claim.
Regards,
[redacted]
September 18, 2014
[redacted]:
I am writing in response to a complaint submitted by [redacted] regarding the denial for a prefabricated post and core on Tooth Number 20 for date of service December 10, 2013. We received your email on September 10, 2014.I searched **. [redacted]’s file per his indication about information sent to us in June, 2014, and found a letter attached to a claimform. I copied the letter and radiograph and had this information reviewed by one of our Dental Advisors. They approved the service and a payment of $63.60 is being sent to **. [redacted] on Friday, September 19, 2014.If I may be of further assistance, please contact me at[redacted]Sincerely,
October 8, 2014
Dear [redacted]:
I am responding to the member's rejection to our response. Your letter was received on October 2, 2014.No refund will be issued for this policy. The member was provided services from the effective date of coverage, May 1, 2014, to present. If the member would like to continue services as of January 1, 2015, they can contact the sales department at ###-###-####, to inquire about coverage where the waiting periods will be waived.I hope this information will be helpful. Please feel free to contact me if you have any questions.Sincerely,Nyla JSpecialized Services Representative
December 16, 2015Dear [redacted]:I am responding to your email dated December 4, 2015, concerning a complaint you received from [redacted], concerning a claim submission problem by an out of network pediatric dentist. We received your email on December 7, 2015.We have not...
received federally required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore, we can only provide a general response to the information you provided in this complaint.A claim for [redacted]'s service in question was received and sent to process as a priority. An Explanation of Benefits statement will be sent to [redacted] on December 18, 2015.Sincerely,Deb R
March
2, Dear *** ***,I am responding to your e-mail received on February 27,
2015, concerning *** ***’s complaint about his claims and how to file an
appealWe have not received federally required HIPAA
authorization from the complainant to release
protected health information
concerning this accountTherefore, we can only provide a general response to
this complaintThis group plan is offered by the U.SOffice Personnel of
Management (OPM)United Concordia Life and Health Insurance administers and
underwrites FEDVIP for OPMAs a Federal plan, FEDVIP is not subject to state
insurance laws.Benefit booklets for FEDVIP members were provided
advising alternate benefit provisions and how to file an appeal. The alternate benefit provision determines how payment is
made when there are two or more clinically acceptable dental services available
to satisfactorily correct the same dental conditionThis provision states that
United Concordia provides coverage for the less expensive service available,
while still ensuring that you receive the quality care you needShould the
member and the dentist choose the more expensive treatment, the member is
responsible for the additional charges beyond the allowance for the alternate
service, even if an in-network providerThis information can be found on page
of the benefit booklet provided to our FEDVIP members.If a FEDVIP member is looking to file an appeal, the
disputed claims process must be followedThe FEDVIP law does not provide a
role for the Office Personnel of Management (OPM) to review disputed claims
The process on how to dispute a claims decision is found on page of the
FEDVIP benefit booklet and outlines the steps that the member would take.Based on the member’s intent to submit an appeal, an
appeal has been submitted on his behalf. *** *** will receive a response once a
determination is made.If *** *** has any additional questions, he may
contact FEDVIP dedicated customer service at ###-###-####.Sincerely,Kayleigh M. Specialized Services Representative
April 18, Dear ***:I am writing in response to your letter dated April 16, 2014, concerning claims for the *** familyWe received this letter on April 16, 2014.The ***’s have a PPO group dental plan through * *** Medical ***This is a self insured
plan and United Concordia provides administrative services only.In the letter, *** provided a listing of service dates for each member of the family that she believes were not processed correctly by United ConcordiaThe following represents our findings:*** ***:Date of Service:September 17, Claim Number: *** Total Charges: $Amount Paid: $153.00*** is responsible for non-covered services which are listed on the Dental Explanation of Benefits statement dated October 3, 2013, which is enclosed.Date of Service:September 25, Claim Number: *** Total Charges: $Amount Paid: 220.15*** is responsible for the provider’s charges less any amount paid for the restorations and deductibleThese amounts are listed on the Dental Explanation of Benefits statement dated October 10, 2103, which is enclosed.*** ***Date of Service:November 29, Claim Number: *** Total Charges: $Amount Paid: $192.00*** is responsible for the non-covered fluoride onlyA copy of the Dental Explanation of Benefits is enclosed.Date of Service:December 4, Claim Number: *** Total Charges: $Amount Paid: $71.00Charges for the scaling and planing + teeth were not considered because x-rays and periodontal charting were not sent by ***It is ***’s responsibility to provide this information so the claim can be reconsideredA Dental Explanation of Benefits statement dated December 6, 2012, is enclosed.Date of Service:April 29, 2013Claim Number: *** Total Charges: $Amount Paid: $41.25*** is responsible for deductible, coinsurance and the service not paid because of frequencyA Dental Explanation of Benefits statement dated May 9, 2013, is enclosed.Date of Service:December and 6, Claim Number: *** Total Charges: $Amount Paid: $ 0No payment was made for these services because the x-rays and periodontal charting were not sent by ***A Dental Explanation of Benefits statement dated June 20, is enclosed.Date of Service:June 11, 2013Claim Number: *** Total Charges: $Amount Paid: $ 0No payment was made because the x-rays were not sufficient to determine eligibility for the servicesA Dental Explanation of Benefits statement dated October 10, 2013, is enclosed.*** ***Date of Service:January 22, Claim Number: *** Total Charges: $Amount Paid: $42.40The member is responsible for coinsurance amountsA Dental Explanation of Benefits statement dated March 21, 2013, is enclosed.Date of Service:July 23,2013Claim Number: *** Total Charges: $Amount Paid: $122.40The member is responsible for coinsurance amountsA Dental Explanation of Benefits statement dated August 15, 2013, is enclosed.*** ***Date of Service:October 1,Claim Number: *** Total Charges: $Amount Paid: $132.00The member is responsible for the non-covered service and the unpaid service due to frequencyA Dental Explanation of Benefits statement dated October 3, 2013, is enclosed.Date of Service:February 18,Claim Number: *** Total Charges: $Amount Paid: $80.00Member is responsible for the fluorideA Dental Explanation of Benefits statement dated February 20, 2014, is enclosed.Date of Service:February 18, Claim Number: *** Total Charges: $Amount Paid: $ 0This claim was reviewed by two Dentist Advisor’s and both determined that payment is not eligible for the services reportedDental Explanations of Benefits statements dated March 27, 2014, and April 10, 2014, are enclosed.If I may be of further assistance, please feel free to contact me directly.Sincerely,
July 15, Dear ***:I am writing in response to your letter dated July 10, 2014, concerning dental coverage for *** ***We received this letter on July 10, 2014.*** is covered as a subscriber under the Individual Dental ProgramThe effective date
of coverage was March 1, 2014, under group number MPAThe situs of this fully insured plan is in Pennsylvania.*** expressed concern that her account was drafted to cover her premium and as a result, she received charges from her bank for an overdraftIn addition, *** wishes to cancel her Individual Dental Plan and receive a full refund.Our records show that the automatic draft of ***’s account was to occur on the 25th of each monthThis is the typical arrangement made when members opt to have funds automatically withdrawn from their account*** reported this created an overdraft on her account and her bank charged her $We received ***’s fax showing the overdraft charge on June 13, A refund check was mailed in this same amount to *** on June 26, 2014.Based on ***’s request, we have requested that her contract be cancelled as “never in force”Currently our records show that a reversed payment was issued back to her account in the amount of $on May 30,A refund in the amount of $will be processed and sent to *** in the near future.If I may be of further assistance, please feel free to contact me directly.Sincerely,
January 6, Dear *** ***:
I am responding to your e mail that was received on December 31, 2014, concerning orthodontic treatment payments.We have not received federally required HIPAA authorization from the complainant to release protected health information
concerning this accountTherefore, we can only provide a general response to this complaint.Under this contract/systematic orthodontic treatment payments are made over the length of treatmentWhen this complaint was received, I called the provider and obtained the treatment completion dateThey confirmed that the subscriber paid item the balance dueWe will pay the subscriber our remaining treatment balance on January 8, 2015.I have enclosed a HIPAA authorization form to complete and return with the subscriber's signature if you need additional information, if *** *** has additjonal questions concerning his plan, he may call Dental Customer Service at ###-###-####.Sincerely, Marta M
Specialized Service Unit
June 29, Dear *** ***:
I am writing in response to a your email that was accessed on June 23, 2015, concerning a preauthorization claim for a crown on Tooth Number by *** ** ***, DMD*** *** is covered as the member under a Dental PPO group plan
through *** *** ***The effective date of coverage was September 1, 2014, under group number ***The situs of the fully insured plan is in Pennsylvania.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim formUnited Concordia dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibility.A Dentist Advisor then reviews the case by studying claims history, reports, correspondence, and diagnostic informationFollowing the review, the claim is processed based on the Dentist Advisor’s opinion and the subscriber’s contractA provider may submit a request for a second review to our Dentist Advisor Unit disputing an advisor denialIf upheld, the provider or subscriber may request an appeal within days from receiptCrown and Onlay approval is based on submitted documentationThe tooth must include at minimum a periapical radiograph, demonstrate a significant loss of tooth structure that the tooth cannot be adequately restored using a direct restoration such as an amalgam or composite; must demonstrate no significant bone loss and the periodontal condition is adequate with no evidence that periodontal treatment is needed and has no periapical pathologyIf a root canal was performed, the radiograph must show the entire apices and demonstrate that the root canal meets acceptable standards of careOn February 13, 2015, we received a preauthorization claim, number *** for a surface porcelain onlay on Tooth Number for *** ***On March 3, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated March 5, 2015.On March 26, 2015, we received a preauthorization claim, number *** *** for a surface resin (white) posterior restoration on Tooth Number for *** ***The service was approved allowing $minus $deductible leaving $payable at percent or a $payment and member’s liability $($deductible and $coinsurance)This was explained on the Explanation of Benefits statement that was sent to *** *** and *** dated March 26, On April 17, 2015, we received a preauthorization claim, number *** for a porcelain ceramic crown on Tooth Number for *** ***On May 6, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (white filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated May 7, On May 21, 2015, we received a call from *** regarding the denial for a crown on Tooth Number We explained how a second review could be requested and at that time the provider can also request a call from the Dentist Advisor during the second reviewOn May 21, 2015, *** called back and asked us to explain how to request a second review to the providerThe representative called the dental office and per ***’s request allowed provider to fax information to representativeThis information was received on May 22, 2015, and forwarded to our Dentist Advisor for a second review (Inquiry Number ***)On May 22, 2015, our Dentist Advisor, MTA***, DDS, performed an independent review and spoke to provider (*** ***) and explained that due to no extensive breakdown, crowns and onlays are not covered to prevent fractures in the futureThis was also explained on the Explanation of Benefits statement dated May 28, *** *** is a participating provider and these denials are not billable to the patient unless *** signed a statement agreeing to pay for the services if they were not approved by her insuranceIf you have any questions, please call Dental Customer Service at ###-###-####Sincerely
Deb RSpecialized Services Representative
--------- Forwarded message ----------From:
"">Revdex.com of Metro Washington DC Date: Wed, Sep 3, at 10:AMSubject: Fwd: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #***.To: *** ***
---------- Forwarded message ----------
From: ***>
Date: Tue, Sep 2, at 6:PM
Subject: Re: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #***
To: [email protected]
I did get a letter from them today saying they are going to pay the dental claim
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:
A "Dental Advisor" decides if a procedure qualifies for coverage, rather than the attending dentist. There is no recourse beyond the appeals process besides "civil litigation." Therefore, any procedure may be rejected at United Concordia's whim, without realistic consumer recourse.
2. I was informed by a customer service representive on 4/(she called me) that United Concordia "sets the bar high" when deciding what will be covered. With regard to periodontal scaling, the company requires the dentist to provide an exceptional amount of documentation as evidenced by this statement:
Procedure RejectedPeriodontal scaling and root planing requires review by a
Dentist AdvisorIn order for the service(s) to be considered, please submit
full mouth duplicate radiograph or digital images and complete periodontal
chartingA complete and compliant or ADA claim form must be submitted
with the requested documentation.Procedure Rejected
With regard to radiographs:
Procedure RejectedPeriapical radiographs performed on the same date as a
periodic oral evaluation requires review by a Dentist AdvisorIn order for the
service(s) to be considered, please submit a copy of the periapical
radiograph(s) or digital images and an explanation of the patient's specific
signs and symptomsA complete and compliant or ADA claim form must be
submitted with the requested documentation.Procedure Rejected
3. United Concordia failed to respond to multiple requests for pre-authorization of work in late 2013/early for family member D. They claim they never received the multiple requests (per phone discussion with "***" on 4/7/14), despite documentation from the dentist showing otherwise. The service was ultimately performed and denied as unnecessary. As an aside, *** also informed me that he speaks with customers who are experiencing similar difficulties with United Concordia "all day long."
Regards,
***
---------- Forwarded message ----------
From: *** ***
Date: Wed, Apr 9, at 11:AM
Subject: complaint #***
To: [email protected]
I just sent a message to them through their contact us form, since they have yet to provide me with a direct email address and I am working the same hours they are so calling and waiting on hold is not really feasible
I explained in my message to them that I did finally receive the refund checkThey sent it to wrong address, my physical instead of my mailing, I live on a nature preserve where there is no way a mailman could even get his little car up my road
The post office was kind enough to call and let me know they had the check and I could pick it up or they could return to sender
I called United Concordia and spoke with a gentleman, explaining that I was worried the check wasn't good anymore and whether I should wait for them to issue a new oneHe told me the check was fine and to go ahead and deposit itThat I would only need to call them back if there was an issue when I deposited it
I deposited it the next day, which was last weekYesterday, the 8th, my bank notified me that a stop payment had been put on the check, the money was taken out and I was charged a $fee for the returned check and a $fee for having to pull money out of my savings to cover it.
I explained to United Concordia my bank is now sending me back the bad check and that a new check will need to be issued that now includes the $in fees I accrued at their fault, making it a total of $
I have asked them to send it to my work address, which I provided and I am awaiting response
Thank you,
*** ***
I am writing in response to your letter dated March 10, 2015, concerning a claim for a buildup and crown for *** *** completed on May 14, We received this letter on March 10, Ms*** was covered as a subscriber under a PPO group plan through NC Flex High OptionThe
effective date was June 1, 2013, under group number ***Her coverage terminated on February 1, The situs of this fully insured plan was in North Carolina.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim formUnited Concordia Dental contracts include provisions requiring input from our Dentist Advisors to determine United Concordia’s financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibilityUnited Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographsFollowing the review, the claim is processed based on the Advisor’s opinion and the subscriber’s contractOn May 22, 2014, we received claim number *** from Dr*** *** for a buildup and crown on Tooth Number Our Dentist Advisor reviewed the information and determined that no payment can be madeThe Dentist Advisor indicated that the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for a buildupNotice was sent to the provider and member on July 24, On August 11, 2014, we received a request for a second review of the buildup and crown on Tooth Number Our Dentist Advisor reviewed the information provided and determined that no payment can be made because the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for the buildupNotice was sent to the provider and member on October 9, On October 22, 2014, we received a request for an appeal of the buildup and crown on Tooth Number Our Dentist Advisor reviewed the information provided and determined that no payment can be madeThe Dentist Advisor states that the service does not meet contractual requirements for paymentCrowns are only covered when the tooth is extensively decayed and/or has a complete cusp fracture and cannot be restored by an amalgam or composite restorationCrown benefits are not available for teeth that may fracture in the futureSince a crown was not deemed necessary, no payment can be approved for a buildupA letter was sent dated November 4, 2014, and an Explanation of Dental Benefits statement dated November 6, was issued to both Ms*** and Dr***Although it is not required, a predetermination is suggestedThis is submitted prior to the services being performed and is reviewed by a Dentist Advisor to determine eligibility and coverage for the proposed services.Since Dr*** is not a participating provider, Ms*** is responsible for the charges for these non-covered servicesIf I may be of further assistance, please feel free to contact me directlySincerely,
Lisa AR***
Specialized Services Representative
###-###-####
March 21, I am writing in response to a complaint that was posted on March 11, 2014, by *** *** regarding her not receiving account information in order to schedule her daughter’s dental appointments, as well as being unable to create an online accountWe received your email
on March 14, 2014.Our research reveals that we received ***’s application for the I-Dental individual plan on February 22, *** was sent an email on February 22, 2014, to inform her that the application had been approvedOn February 25, 2014, we sent an email to *** informing her that her bill was ready to be viewed.There is no record of *** calling either United Concordia’s Customer Service department or the Billing and Enrollment departmentThe email address that’s posted on ***’s file is *** and there are no emails in our mailbox or the archives from this addressOur clerical department also posts emails and images they receive from a member’s caseNo logs of this kind are posted on ***’s file.Due to the unfortunate circumstances *** experienced, we have terminated her case, *** and requested an expedited refund of $This was requested on March 17, 2014, and expedited refunds usually take three to five business days to process.If I may be of further assistance, please contact me.Sincerely
[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved]
Complaint: ***
I am rejecting this response because:
United Concordia should not have turned me over to collections in the first place I called them multiple times requesting I be removed from collections, which they assured me I had been According to the collections agency I am still in collections The last time I called United Concordia about it I was told that because they couldn't know which agency they turned my case over to I would have to contact the collections agency directly which I have now had to do multiple times They told me to tell the collections agency that United Concordia said I didn't owe them any money As ludicrous as that sounds I did it anyway because I don't want this to affect my credit
The collections agency laughed when I told them that and said that was not how it worked They told me I was still on their collections list They could not tell me if this continuing and unfortunate situation affected my credit rating so as a result I have had to and will have to continue to pull my credit report
United Concordia's abysmal customer service and unethical business practices has taken a great deal of time out of my life Had they processed my payments on time initially or handled the situation properly at any point subsequently, none of this would be happening
Regards,
*** ***
March 9, 2015Dear *** ***:I am responding to your email received on March 2, 2015, concerning dental services provided on December 4, 2014, and January 21, 2015, by *** *** *** *** *** of Pottstown, Pennsylvania.We have not received federally required HIPAA
authorization from the complainant to release protected health information concerning this accountTherefore, we can only provide a general response to the information you provided in this complaint.*** *** is enrolled as the subscriber under an *** *** *** (***) Dental Health Maintenance Organization (DHMO) *** *** *** dental plan that is administered by United Concordia.This DHMO plan requires services to be provided by the patient's assigned, participating, Primary Dental Office (PDO)When *** *** requested a PDO change on December 4, 2014, *** was unable to make this change to this provider's non-participating Pottsville, Pennsylvania location where these services were provided*** *** *** *** *** does participate in Collegeville, Pennsylvania, which is located within less than ten miles from the subscriber's home zip codeOn March 12, 2015, we will pay the provider as an exception for services provided on January 21, 2015, as if they were provided by her assigned PDOWe will do the same for services provided on December 5, 2014, if we receive that claim, which we requested twice from her provider.| called *** *** on March 4, 2015, and explained thisShe called me back on March 9, 2015,and states she does not want to change her PDO at this time because they do not bill her all the co-pays she would oweShe will fax me a claim for the services provided December 5, 2014.If you need additional information concerning these services, I have enclosed a HIPAA authorization form for you to return to us after it is completed and signed by the subscriber.If MsFritz has additional questions concerning these services, she may call me at the number provided her, or she may call Blue Extra Dental Customer Service at ###-###-####If you have any questions concerning the release of protected health information, please call our Privacy Department at ###-###-####.Sincerely,Marta M
SrService Representative Dental Customer Service Specialized Service Unit
Dear *** ***:
I apologize that you have been experiencing these many difficulties when trying to get your reimbursement However, please be aware that we are making every effort possible to assist you with your efforts
Yes, you may scan and email the documents to: ***
*** *** has informed me that when he receives the information, he will take care of it right away
Thanks
*** ***
[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 [redacted], and find that this resolution is satisfactory to me.
Regards,
[redacted]
Dear [redacted],
The phone calls are recorded - as stated by the message on tape when you call for help or questions. I urge you to ask for the tape of my conversation with Ms. M[redacted] regarding this problem. At NO TIME did Ms. M[redacted] mention anything regarding a co pay was to be paid by me for the bill. The words co-pay never even came up when I spoke about Ms. M[redacted] covering the bill. Yes, we did have a conversation about changing offices, which Ms. M[redacted] THEN STATED that a $45 fee would be due if I selected a nearby office. I told her that I never paid a $45.00 fee when I went to University of [redacted] and I had went there for over a year. We laughed and said that it was worth the drive and the lack of problems with billing to go to U of *. Never at any time did Ms. M[redacted] instruct me that the $90 was due - as she told me "as an exception we will cover this bill".
I am tired of this going back and forth - I will accept what ever is determined. I just hope that the phone call of our recorded phone call can be obtained before a final decision is made.
Thank You for all your help,
[redacted]
October 21, 2014Dear [redacted]:I am writing in response to your letter dated October 17, 2014, concerning [redacted]. We received this letter on October 17, 2014.As indicated previously, we contacted the premium center and confirmed [redacted] is not in a collection status with United Concordia. It may take several weeks for [redacted]’s files to be cleared by the collection agency. Unfortunately, we cannot control the speed at which this agency handles their files.If we may be of further assistance, please feel free to contact Dental Customer Service at: ###-###-####.Sincerely,
Lisa RSpecialized Services Representative
Complaint: [redacted]
I am rejecting this response because:I want United Concordia to finally pay what they owe for a procedure I had done in December 2013. This company has shown a clear pattern of avoidance of payment. They have spent so much of my time and my dentist’s and kept asking for more evidence, information to be filed on different forms, that my dentist has threatened to report them to the Ohio Department of Insurance. I hope that he does. They have created so many hoops to jump through, and made the process as difficult as possible, clearly avoid paying for a simple crown. Nothing we send them is good enough, and they make the process as difficult as they can. Just one example of many; they will not accept FAXed information from my dentist. Everyone and their brother has a FAX machine, and can send and receive FAXes. They are built into even inexpensive printers. A large part of this company’s business is (or should be) communicating with their customers. Yet, when my dentist wanted to FAX them information, when they said they had not received the 2 claims they had sent by mail, a UC rep, said “We WILL NOT accept FAXed information”. How is this good in any way for the clients and providers who try to send them information? It does however make the process of getting claims processed more slow and difficult, which would result in more money for the insurance company; they can keep the money in their bank account longer earning interest and making the process more difficult will mean that more people give up on getting their claims paid, which equals more money in the insurance company’s ‘pockets. As we come up on almost of year of haggling with United Concordia, my Dentist has told me that he met their latest demands back in June, sent what they asked for this time - a different X-ray than the first one he sent, and a narrative of what was done and why. So, I get an explanation of benefits from United Concordia dated August, again denying payment, which vaguely states “additional information was required to process these services. The provider should resubmit these services….” This is the most evasive, slippery, unethical insurance company I have ever dealt with.Quit giving myself and the dental provider the run around, and putting up hurdles to payment, and pay this legitimate claim.
Regards,
[redacted]
September 18, 2014
[redacted]:
I am writing in response to a complaint submitted by [redacted] regarding the denial for a prefabricated post and core on Tooth Number 20 for date of service December 10, 2013. We received your email on September 10, 2014.I searched **. [redacted]’s file per his indication about information sent to us in June, 2014, and found a letter attached to a claimform. I copied the letter and radiograph and had this information reviewed by one of our Dental Advisors. They approved the service and a payment of $63.60 is being sent to **. [redacted] on Friday, September 19, 2014.If I may be of further assistance, please contact me at[redacted]Sincerely,
October 8, 2014
Dear [redacted]:
I am responding to the member's rejection to our response. Your letter was received on October 2, 2014.No refund will be issued for this policy. The member was provided services from the effective date of coverage, May 1, 2014, to present. If the member would like to continue services as of January 1, 2015, they can contact the sales department at ###-###-####, to inquire about coverage where the waiting periods will be waived.I hope this information will be helpful. Please feel free to contact me if you have any questions.Sincerely,Nyla JSpecialized Services Representative
December 16, 2015Dear [redacted]:I am responding to your email dated December 4, 2015, concerning a complaint you received from [redacted], concerning a claim submission problem by an out of network pediatric dentist. We received your email on December 7, 2015.We have not...
received federally required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore, we can only provide a general response to the information you provided in this complaint.A claim for [redacted]'s service in question was received and sent to process as a priority. An Explanation of Benefits statement will be sent to [redacted] on December 18, 2015.Sincerely,Deb R
Please see United Concordia's response attached above for case ID [redacted]