United Concordia Companies

Please see United Concordia's response attached above for case ID [redacted]

Good Afternoon [redacted] United Concordia received complaint ID [redacted] from your department on 7/28/ Based on the information provided we are unable to identify the subscriber and address their concerns We tried calling the member at the phone number referenced on the complaint but was unable to contact the subscriber We would need a valid United Concordia identification number to address the concerns in this complaint Thank you, Amy *R [redacted]

April 20, 2015Dear [redacted] :I am responding to your email received on April 15, 2015, requesting payment in full for dental services provided on December 4, 2014, and January 21, 2015, by [redacted] of Pottstown, PennsylvaniaWe have now paid both of these services dates as an exception to the contract.I sent the HIPAA authorization from included with this request to our Privacy Department for reviewThey will notify the subscriber of their decision when their review is completed.When I previously spoke to [redacted] on March 9, 2015, I told her these claims would be paid in accordance with the dental contract, as they haveI did not state they would be paid in fullIn fact, I told her the contract requires her to pay co-pays for the procedures providedThis is when she decided not to change her PDO because she said her current PDO does not bill her copays as they canWe c***ot discriminate against other group members with the same co-pays by paying claims differently for [redacted] ***.I sent [redacted] a copy of her dental benefits and co-pay schedule which lists her liability for the procedures performed.Sincerely, Marta M SrService Representative Dental Customer Service Specialized Service Unit

I am responding to your email, which we received on April 22, 2016, concerning a denied claim for dental services provided for the subscriber's wife on February 1, Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to provide protected health information without the patient's written consenthave enclosed a copy of our Request and Authorization for Disclosure of Health Information formPlease resubmit your request with this completed form if you need detailed informationPlease contact me if you have any additional questionsSincerely,Marta M***, SrService RepresentativeDental Customer Service Specialized Service UnitEnclosure

September 3, Dear [redacted] :I am responding to your email received on August 25, 2015, concerning a complaint you received from [redacted] ***, regarding his dissatisfaction with processing his claim by non-participating provider [redacted] **We received this email on August 25, 2015.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 complaintThe claim was received without the required diagnostic materialsA payment was issued to the provider on August 27, 2015, for the services that did not require review or diagnostic materialsI spoke with the provider’s office on September 02, 2015, and they have agreed to send the required diagnostic materialsOnce received, I will send the claim and the attachments for processing.A detailed explanation was sent to the Commonwealth of Virginia replying to a complaint they received from [redacted] regarding the same issueI have enclosed a HIPAA authorization form for you to return with the subscriber’s signature if you need additional informationIf you have any questions concerning this form, please call our Privacy Department at ###-###-####If [redacted] has additional questions, he may call Dental Customer Service at ###-###-####Sincerely, Deb RSpecialized Services Representative

[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 Although, I did not receive the check sent out on May 30th as they reportAre we able to look further into this? They can research into their accounting records that it was never cashedIs it able to be resent or credited directly to my bank account? Regards, [redacted]

December 29, I am responding to your email received December 22, 2015, concerning multiple claims for multiple patients, and the submission of necessary documentation with certain proceduresWe have not received a federally required HIPAA authorization from the patients involved with this complainant to release protected health information concerning these accountsTherefore, I can only provide a general response to this complaint.On December 28, 2015, I contacted the office and spoke with [redacted] to better address the issue concerning the denials of claims and the necessary documentation that should be included with the claimsI informed her how to locate the information via the provider portal in our website, information in our Dental Reference Guide regarding our policies, diagnostic material requirements, claims address, and submissions for appeals and second reviewsI am currently working with [redacted] to help her with a claim for a specific member and left communication open between us, in case she may have any additional questions regarding submissions, reviews, policies, etcIf you have any additional questions, feel free to contact meSincerely, Serena WSpecialized Services Unit Representative

[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: [redacted] I am rejecting this response because: My credit is still under threat I will be satisfied to close this complaint when I receive written confirmation from the collections agency indicating I am not longer being pursued for this money Please submit this to me Thank you Regards, [redacted]

May 16, Dear [redacted] :I am responding to your e-mail dated May , 2013, questioning services provided on December 27, 2013, that denied due to exceeding the maximum.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[redacted] is enrolled as the subscriber under a Fee For Service group dental plan through the State of MarylandHer coverage is effective October 16, 2006, under Group Number [redacted] .The State of Maryland had a short plan year covering July to December 31, Prior to the groups open enrollment period from April to April 30, 2013, the State of Maryland notified their employees that they should read the Open Enrollment materials mailed to their home or provided by their Agency Benefits Coordinator to learn how this short plan year affects their benefitsThey provided their website, www.dbm.maryland.govbenefits, which states that the maximum was prorated for this short plan yearThe PPO Schedule of Benefits they provided lists the maximum per member during the period of July to December 31, 2013, as 750.00, excluding Class I services for diagnostic and preventative servicesThese benefits were available to the subscriber or provider prior to treatment on our Automated Voice Response telephone system at ###-###-####, on our website at www.ucci.com, or by a Dental Customer Service Representative at ###-###-####We document all telephone calls and correspondence receivedThere is no record that we gave incorrect benefits prior to treatment or that we stated these procedures would be paid.According to our records, we paid for dental services provided for [redacted] from July 1, to December 31, that were not Class I servicesThe dental services provided on December 27, were not Class I servicesTherefore, no additional payment can be made for the services provided on December 27, 2013, that denied correctly as exceeding the maximum.I have enclosed a HIPAA authorization form for you to return with the subscribers signature if you need additional informationI have also enclosed a copy of information the state provided their members concerning this maximum prior to July 1, 2013.If [redacted] has additional questions, she may call Dental Customer Service at ###-###-####.Sincerely,

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 This company has shown a clear pattern of avoidance of paymentThey 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 InsuranceI hope that he doesThey have created so many hoops to jump through, and made the process as difficult as possible, clearly avoid paying for a simple crownNothing we send them is good enough, and they make the process as difficult as they canJust one example of many; they will not accept FAXed information from my dentistEveryone and their brother has a FAX machine, and can send and receive FAXesThey are built into even inexpensive printersA large part of this company’s business is (or should be) communicating with their customersYet, when my dentist wanted to FAX them information, when they said they had not received the 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 ‘pocketsAs 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 whySo, I get an explanation of benefits from United Concordia dated August, again denying payment, which vaguely states “additional information was required to process these servicesThe 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]

May 14, [redacted] :I am writing in response to a complaint submitted on May 4, by [redacted] regarding the denial for a prefabricated post and core on Tooth Number provided on date of service December 10, We received your email on May 5, 2014.** [redacted] is covered as the member under the [redacted] ( [redacted] ) effective January 1, 2011, under Group Number [redacted] This program is offered by the U.SOffice of Personnel Management (OPM)United Concordia administers and underwrites [redacted] for OPMAs a Federal plan, [redacted] is not subject to state insurance lawsAs a courtesy, I am providing you with the following information.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.United 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 contract.On January 27, 2014, we received claim number [redacted] for date of service December 10, 2013, for a prefabricated post and core on Tooth Number The Dental Claims Department recognized that this non-participating provider ( [redacted] * [redacted] , DMD) submitted services on an unacceptable dental claim form and sent a letter to Dr [redacted] explaining how to obtain an acceptable claim formA copy of this letter is enclosed for your reference.The provider community was informed of updates to the claim form on the American Dental Association website (www.ada.org), United Concordia’s website (www.ucci.com1), the ADANewsand United Concordia’s newsletter the Connection.On March 17, 2014, we received claim number [redacted] for a prefabricated post and core on Tooth Number On March 24, 2014, a letter was sent to Dr [redacted] requesting a pretreatment radiograph of Tooth Number (prior to crown preparation/insertion) of the completed root canal showing the entire apicesThe claim denied because we did not receive the requested information within the allotted timeframeA copy of this letter is enclosed for your reference.On March 26, 2014, ** [redacted] called United Concordia questioning the status of his claim for date of service December 10, 2013, and was advised we needed an X-ray showing the apices.I spoke to [redacted] and Dr [redacted] on May 14, 2014, and explained what was required for a second review and where to send the information.If I may be of further assistance, please contact me

April 24, Dear ** [redacted] :I am writing in response to your letter dated April 21, 2014, concerning [redacted] ’s questions about our response dated April 18, We received this letter on April 21, 2014.** [redacted] questioned our “Dentist Advisor” making decisions on patient treatmentUnited Concordia would never propose that patients deny themselves necessary careIn all situations, a provider must use their professional judgment to provide care they believe to be in the best interest of the patientAs always, the dentist and member are responsible for treatment decisionsOur determinations are made for coverage purposes only and cannot supersede the professional judgment of the treating dentist.** [redacted] states that United Concordia expects an exceptional amount of documentation with regard to periodontal scaling and root planing servicesAll 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 responsibility.United 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 contract.In addition, ** [redacted] questions our policy with regard to periapical radiographsPeriapical radiographs performed on the same date as a periodic oral evaluation requires review by a Dentist AdvisorThis policy was put in place in part to prevent routine taking of radiographs, unless a specific reason is documented and in keeping with the American Dental Associations recommendation on taking of periapical radiographs without a specific diagnostic reason** [redacted] believes that United Concordia did not respond to multiple requests for a dental predetermination submitted by Dr***As was indicated during conversations with ** [redacted] , we have never received a predetermination request for any services to be provided by Dr***We did receive a claim for services dated February 18, 2014, for ***However, prior to those services actually being done on that date, we did not receive any request for a predetermination for services to be provided by Dr***.If I may be of further assistance, please feel free to contact me directlySincerely,

[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: [redacted] I am rejecting this response because: We are aware of everything stated in this letterIn fact, all it says that we began with United Concordia in May and will no longer be enrolled as of Jan THE ISSUE WE HAVE IS THAT THERE IS A MONTH WAITING PERIOD BEFORE WE ARE ABLE TO USE THIS INSURANCESO WE HAVE PAID FOR THIS INSURANCE SINCE MAY BUT WE WILL NEVER GET TO USE THIS INSURANCE BECUASE WE WILL NO LONGER BE ENROLLED AS OF JAN We would like a refund of our money because we never even got past our waiting periodAs stated in previous email (see below) - we would like a refund; We would like our money back We each have paid - Year to date $ We have separate policies: [redacted] - Member ID# [redacted] - Plan/Group# [redacted] - Member ID# [redacted] - Plan/Group # [redacted] Regards, [redacted]

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 dentistWe 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 accountTherefore, 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 priorityAn Explanation of Benefits statement will be sent to [redacted] on December 18, 2015.Sincerely,Deb R