Beverly Healthcare

[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 as Answered] Complaint: [redacted] I am rejecting this response because: I absolutely and categorically reject the response from United Concordia I need to ask, once again, and refer MrMathew S [redacted] to Section 7, pages and General Exclusions - Things We Do Not Cover of my United Concordia [redacted] plan DOES NOT include nor does it even show the 3-words, attrition, erosion or abrasion The 7th bullet on page of the General Exclusions does NOT mention or show the words "attrition, erosion or abrasion." MrS [redacted] has now advised me twice by phone calls that the Primary Reason for denying this Claim is due to the word "EROSION" So once again, I need to ask for United Concordia Dental to explain this?I will be taking this latest response from United Concordia dtd Sept23, to my Wife's (and my) Dentist for their Professional Review, evaluation and opinion In addition, I will wait for the a response from my 1st Appeal letter rec'd by United Concordia on Sept22, I will continue to exercise my Appeal Rights if necessary Regards, [redacted] ***

------- Forwarded message ----------From: Revdex.com of Metro Washington DCDate: Mon, Nov 21, at 9:AMSubject: Fwd: Complaint File # [redacted] To: [redacted] < [redacted] @myRevdex.com.org>---------- Forwarded message ----------From: [redacted] *** < [redacted] @ [redacted] .com>Date: Sat, Nov 19, at 10:AMSubject: Complaint File # [redacted] To: [email protected] your e-mail did not allow for a response, I am responding through this e-mailYesterday, I did receive payment from [redacted] for my dental claim that they processed incorrectlyMy Revdex.com file has been labeled as "no response from complaintant", but issue was not resolved until payment was actually receivedAs of 11/18/16, complaint from issue beginning in June of 2016, has been resolved[redacted] ***

Date Sent: 9/23/12:36:PMSeptember 23, 2016Dear [redacted] ,I am writing in response to a letter we received from the Revdex.com dated September 15, 2016, concerning crowns and buildups for the subscriber's spouse.Regarding claim [redacted] we researched why the claim was paid and discovered that a claims processing error occurred and the services were approved without ever having being reviewed by a Denta! AdvisorThe claim was processed and approved one day after receipt of the claimThe review process normally takes approximately three weeksThis claim should not have been paidAccording to the plan benefit services rendered due to attrition, erosion, and abrasion are part of the exclusionHowever, we will not be seeking a refund for this service.All claims are processed according to the terms of the subscriber's contract and the information reported on the claim formIn the [redacted] benefit booklet, section seven, under General Exclusions on page 29, the seventh bullet point specifically states: Services to alter vertical dimension and/or restore or maintain the occlusionSuch procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.Teeth that are naturally ground down due to wear and tear are provided crowns to restore the vertical height of the teeth so that the patient's natural bite height is restoredThis would be the same as altering the vertical dimension.On September 22, 2016, we received an inquiry requesting an appeal for the crowns in questionA letter will be sent to the subscriber and provider advising of the outcome once completed, which will advise of additional appeal rights if necessary.Sincerely,Matthew S.Specialized Services Unit Representative

January 11, 2017Dear [redacted] :I am responding to your letter dated January 5, 2017, which we received on January 6, 2017, concerning customer service issues involving a claim.We have not received specific claim information or federally required HIPAA authorization from the Complainant as required before we can release protected health information concerning a claim,I have enclosed a HIPAA authorization form that the subscriber can complete and return to you for your resubmission of this request with that authorization, and with the specific claim information that you are questioningIf the subscriber has any questions concerning their dental plan, they may call Dental Customer Service at ###-###-####.Sincerely,Marta M., Specialized Service Unit Dental Customer Service

[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]

[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 as Answered] Complaint: [redacted] I am rejecting this response because:If they would like to send me the Authorization, I would be happy to sign it and return it to them Please let me know if there is anything I can do to assist with this matter 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

January 15, 2016Dear [redacted] :I am responding to your email dated January 8, 2016, concerning a complaint you received from [redacted] , and the participation and/or non-participation of a dental officeWe received your email on January 8, 2016.We have not received a federally required HIPAA authorization from the complainant to release protected health information concerning this account.Sincerely,Deb R.Specialized Services Representative

-------- Forwarded message ----------From: Revdex.com of Metro Washington DC Date: Mon, Nov 28, at 10:AMSubject: Fwd: Attn: [redacted] # [redacted] To: [redacted] ---------- Forwarded message ----------From: W [redacted] Serena < [redacted] @***.com>Date: Mon, Nov 28, at 9:AMSubject: RE: Attn: [redacted] # [redacted] To: "[email protected]" [redacted] I’m sorry for the late responseI did receive your voicemail, and I just realize I did, in fact, forget to provide the attachmentI know in your voicemail you stated the case was closed, but here is the attachment with the response for your record as well Thank you and happy holidays!Serena W [redacted] Serena *W [redacted] Specialized Services UnitMember & Provider ExperienceDeer Path Road, Harrisburg, PA UNITED CONCORDIA DENTALProtecting More Than Just Your Smile®

[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 As additional information: I made a call to the business on December 10th to inquire about the faxed copy of the document I had sent days beforeIt was lost within the companyI was again given permission by Brian N to have it faxed yet again from the provider with a promised phone call when it was receivedI called again Tuesday December 15th as I received no such call and was told that it had been received and he would send it on to the claims department at some point that dayI am hopeful that the 4th time sending this document will be the one that finalizes this transaction Regards, [redacted]

June 23, 2016Dear [redacted] :I am responding to your June 17, email, which we received on June 17, 2016, concerningour payment amount for a dental service provided for [redacted] ***.Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to respond with a patient's protected health information without their written ConsentI have enclosed a copy of our Request and Authorization for Disclosure of Health Information form for that purposeOnce this form is completed, please include it with your resubmitted request to the Privacy Department listed on the form.We can only state that we paid the dental service correctly in accordance with the dental contact.Please contact me if you have any additional questions.Sincerely,Marta M.SrService 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: ***
Hi, Regarding my case, United Concordia asked me to fill some documents, please find it attached (please do not share the attachment the website of Revdex.com)
Regards,
*** ***

September 3, 2015Dear *** ***:I am responding to your email received on August 25, 2015, concerning a complaint you received from *** ***, regarding his dissatisfaction with processing his claim by non-participating provider *** ** *** **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 complaint.The 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 *** *** regarding the same issue.I 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 *** *** has additional questions, he may call Dental Customer Service at ###-###-####.Sincerely,Deb R.Specialized Services Representative

September 20, 2016Dear *** ***:I am responding to your email, which we received on September 12, 2016, concerning a claim for dental services provided for a dependent of *** *** on February and February 18, 2016.Due to the Federal Health Insurance Portability and Accountability Act
(HIPAA Privacy Act), we are unable to respond with a patient's protected health information without their written consentI have enclosed a copy of our Request and Authorization for Disclosure of Health information form for that purposePlease resubmit your request with this completed form if you need detailed informationThe dependent in question is over the age of and the dependent must be the one to provide the written consent.Please contact me if you have any additional questions.Sincerely,Tamera S., SrService Representative Dental Customer Service Specialized Service Unit

* *** *** *** *** *** ** *** *** *** *** *** ** *** *** *** *** ** *** ** *** *** ** *** *** *** *** *** *** ** *** *** *** ** *** *** *** *** *** ** *** *** ***
*** *** ***
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me.
Regards,
*** ***

[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:my policy covers crown
Regards,
*** ***

The following information will assist you in contacting us if you need additional assistanceThe information provided on this cover letter is not intended for the complainant.Specialized Services Unit Business Hours: 8:a.mto 8:p.m.Toll Free Number: ###-###-#### Fax Number:
###-###-####United Concordia Companies, Inc.P.OBox *** Harrisburg, PA ***Sincerely,Specialized Services Unit 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 *** and will sign and submit the release of information
Regards,
*** ***

I am writing in response to your correspondence that we received on October 19, 2015, concerning the crown and buildup denial for *** *** *** Tooth Number rendered by Christopher LS*** ***, on January 29, 2015.*** *** *** is covered as the spouse under a PPO group dental plan through ***Her coverage was effective August 19, 2012, and cancelled on March 1, The group is self-insured, for which United Concordia Companies Incorporated provides administrative services onlyThe state of Colorado has no jurisdiction over this self-funded group planHowever, as a courtesy, I am happy to provide the following information regarding the service in question.We received a claim for a crown and buildup on Tooth Number that denied due to periodontal pathology and a short root canal fillThe service received two independent reviews by two different licensed dentist advisors and one appeal by an independent licensed dentist advisorThe denial was upheld on all levels due to the aforementioned reason(s)

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, 2016.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 information. Please contact me if you have any additional questions.Sincerely,Marta M***, SrService RepresentativeDental Customer Service Specialized Service UnitEnclosure