Beverly Healthcare

February
12, 2016Dear
[redacted]:I...

am
writing in response to the email received from the State of Washington
Insurance Commissioner dated February 1, 2016, concerning a claim for scaling
and root planing for Tooth Numbers 14 and 18 completed on July 13, 2015, and
the upper and lower right quadrants completed on August 3, 2015, for [redacted]. We received this letter on February 1, 2016. [redacted]
was covered as the spouse under a fully insured Dental PPO group plan through Group
Health Cooperative Direct Pay.  The
effective date of coverage was March 1, 2015, to November 1, 2015, under group
number [redacted]. United Concordia administers the dental claims and benefits
for this group. The situs of this fully insured plan was in Washington.All
claims are processed according to the terms of the subscriber’s contract and
the information reported on the claim form. United Concordia dental contracts
include provisions requiring input from our Dentist Advisors to determine
financial responsibility. We are responsible for ensuring that payment is
appropriate for the care our subscribers receive. Our dental review program
fulfills this responsibility. Scaling and root planing is indicated for a
patient with periodontal disease and is therapeutic, not prophylactic, in
nature. For this treatment to be approved, diagnostic materials must
demonstrate clinical loss of periodontal attachment, crestal bone loss or
changes in crestal lamina dura, probing depths of 4 m.m. or greater, and
bleeding points and/or evidence of root surface calculus. If bone loss is not
evident and/or deposits involve enamel surfaces only, the service rendered is
either a prophylaxis or a full mouth debridement. For these services to be
reviewed we need a full mouth series of x-rays and current periodontal charting
submitted. On July 13, 2015, we received claim [redacted]
for scaling and root planing on the upper and lower right quadrants completed
July 13, 2015. At the time, the member’s account premium payments were not up
to date and the claim denied stating the member was not covered at the time of
service. An Explanation of Benefits was mailed on August 6, 2015.On August 27, 2015, we received claim [redacted]
for scaling and root planing on the upper and lower right quadrants completed
on July 13, 2015. We did not receive any of the information needed, the claim
denied. We mailed an Explanation of Benefits to the member and provider on
September 3, 2015.On August 31, 2015, we received claim [redacted]
for scaling and root planing on Tooth Numbers 14 and 18 completed on August 3,
2015. We did not receive the information needed to process the claim, the claim
denied. An Explanation of Benefits was mailed on September 3, 2015.On
September 14, 2015, we received claim [redacted] for scaling and root planing
on the upper and lower right quadrants completed July 13, 2015, and limited
site for 1-3 teeth in the other two quadrants that were not listed, completed
August 3, 2015. Our Dentist Advisor, S. A. R[redacted], DMD, reviewed the
information for the upper and lower right quadrants on September 18, 2015, and
stated there did not appear to be loss of attachment due to the periodontal
disease and denied the services, and noted there were no Tooth Numbers provided
for the limited site in the other two quadrants, so a review could not be completed.
An Explanation of Benefits was mailed to the member and provider informing the
denial for upper and lower right quadrants and requesting to resubmit a
corrected claim with the individual tooth numbers to have a review completed on
September 24, 2015.On
September 28, 2015, we received claim [redacted] for scaling and root planing
on Tooth Numbers 2, 14, 18, and 30 completed July 13, 2015. Our Dentist
Advisor, S. A. R[redacted], DDS, reviewed the information on September 30, 2015,
and notated there did not appear to be loss of attachment due to the
periodontal disease, and denied the claim. An Explanation of Benefits was
mailed to the member and provider on October 1, 2015. On
October 12, 2015, we received a request for a second review for the scaling and
root planing services. Dr. Nash requested to speak with an advisor.  Our Dentist Advisor, M. T. A[redacted], DDS,
called and spoke with Dr. [redacted] on November 16, 2015, and explained the criteria
for the services and why the claim was being denied. An Explanation of Benefits
was mailed to the member and provider on November 19, 2015.There
is still an appeal left for these services. If [redacted] or Dr. Nash has any additional
information please send it to: Appeals P. O. Box [redacted] Harrisburg, PA [redacted]. The
appeal must be submitted within 180 days of the notice of the most recent
advisor denial.If you have any further questions, feel free to contact me.Sincerely,Serena *. W[redacted]Specialized Services Unit Representative

The following information will assist you in contacting us if you need additional assistance. The information provided on this cover letter is not intended for the complainant.Specialized Services UnitSincerely,Serena W. Specialized Services Unit Representative

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 office. We 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

June 23, 2016Dear [redacted]:I am responding to your June 17, 2016 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 Consent. I have enclosed a copy of our Request and Authorization for Disclosure of Health Information form for that purpose. Once 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.Sr. Service Representative

December 15, 20l7Dear [redacted]:This is in reply to your inquiry concerning the complaint that you received from [redacted]regarding coverage through the [redacted] Dental Program (TDP) under United Concordia (UCCI) for thefamily coverage under [redacted].The TDP, offered by the...

Department of Defense (DoD) through the Defense Health Agency (DHA),provides worldwide coverage. UCCI administers and underwrites the TDP for the DHA as of May 1, 2017.Our records currently indicate that the Family coverage for [redacted] family was effectiveMay 1, 2017. Coverage ended September 1, 2017. TDP was not able to receive automatic premiumpayments from the sponsor‘ s military pay.Our records indicate that initial contact was received from [redacted] on October 3, 2017, and a supervisorcallback was requested on November 29, 2017. On December 12, 2017, [redacted] was contacted by TDPSupervisor Shavonne M[redacted] and advised of information required to reinstate coverage to show currentthrough January 2018 with no break in coverage from May l, Z017, when UCCI started administering theTDP contract. During this phone call, [redacted] even praised the service she received on a previous phonecall because the representative took the time to explain and educate her on the next step.If we can be of further assistance please contact the [redacted] Dental Program customer servicedepartment at *-###-###-####.Sincerely,United Concordia

-------- Forwarded message ----------From: Revdex.com of Metro Washington DC <[email protected]>Date: Mon, Nov 28, 2016 at 10:02 AMSubject: Fwd: Attn: [redacted]To: [redacted] <[email protected]>---------- Forwarded message ----------From: W[redacted] Serena <[redacted].com>Date: Mon, Nov 28, 2016 at 9:59 AMSubject: RE: Attn: [redacted]To: "[email protected]" <[email protected]>[redacted] I’m sorry for the late response. I did receive your voicemail, and I just realize I did, in fact, forget to provide the attachment. I 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 Experience4401 Deer Path Road, Harrisburg, PA 17110  UNITED CONCORDIA DENTALProtecting More Than Just Your Smile®

August 26, 2016Dear [redacted]:I am responding to your email, which we received on August 15, concerning a predetermination of benefits claim for the member.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 consent. have enclosed a copy of our Request and Authorization for Disclosure of Health information form. Please resubmit your request with this completed form if you need detailed information.We can only state that the predetermination was received several times without the required diagnostic materials.Please contact me if you have any additional questions.Sincerely,Laura B. Lead Customer Service Representative Dental Customer Service Specialized Services Unit

------- Forwarded message ----------From: Revdex.com of Metro Washington DC<[email protected]>Date: Mon, Nov 21, 2016 at 9:41 AMSubject: Fwd: Complaint File #[redacted]To: [redacted] <[redacted]@myRevdex.com.org>---------- Forwarded message ----------From: [redacted] <[redacted].com>Date: Sat, Nov 19, 2016 at 10:42 AMSubject: Complaint File #[redacted]To: [email protected] your e-mail did not allow for a response, I am responding through this e-mail. Yesterday, I did receive payment from [redacted] for my dental claim that they processed incorrectly. My Revdex.com file has been labeled as "no response from complaintant", but issue was not resolved until payment was actually received. As of 11/18/16, complaint from issue beginning in June of 2016, has been resolved.[redacted]

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. 
Regards,
[redacted]

December 29, 2015I am responding to your email received December 22, 2015, concerning multiple claims for multiple patients, and the submission of necessary documentation with certain procedures.We have not received a federally required HIPAA authorization from the patients involved with this...

complainant to release protected health information concerning these accounts. Therefore, 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 claims. I 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 reviews. I 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, etc.If you have any additional questions, feel free to contact me.Sincerely,Serena W.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 [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 30 days before. It was lost within the company. I was again given permission by Brian N to have it faxed yet again from the provider with a promised phone call when it was received. I 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 day. I am hopeful that the 4th time sending this document will be the one that finalizes this transaction.
Regards,
[redacted]