Highmark Blue Cross Blue Shield Delaware

Review: I have several hours tied up in this along with $63.29 of our money, the frustration of their freezing my wifes medical card and verbally being told what the root of the problem was during a phone conversation with a BCBS customer service representative, something that if they told us back in January would have solved this issue upfront. Based on my phone conversation with BCBS, it appears that the October 28, 2013 medical services provided to my wife and as processed by BCBS on January 10, 2014 was funded from 2014 medical funds and not the 2013 funds as it should have been. Instinctively, I processed the payment on my wifes medical card when the bill came in when I should have processed some other way via a check request or something against the balance of 2013 medical funds. It would have been nice if someone took the time earlier in contacting and explaining this to me beforehand instated of continuing to send me form letters of which I continued supplying the correct requested information from the October 28th, 2013 medical services. It should be noted that the October 28th, 2013 medical services were not applied against the 2013 funds and to the best of my recollection there was $205.85 of available 2013 funds to pay this expense.Thank youDesired Settlement: It is my understanding that by law my $63.29 can't be paid from the 2013 medical balances after the first 90 days of 2014, thus I'm seeking reimbursement of these funds directly from BCBS De. If a was provided forms for proper reasoning by BCBS De within the first 90days, I would have been reimbursed from the 2013 funds accordingly.

Business

Response:

Please find Highmark Blue Cross Blue Shield Delaware's response to Complaint # [redacted] attached.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. I am GREATFUL for your interaction after having spent hours filing an appeal only to be denied on the same "90 days too late" bases. Having complied with everything they repeatedly asked for during the first 90 days, a simple form letter advising (reminding) me that I need to process 2013 expenses otherwise during those 90 days would have been extremely beneficial to us all.Again I thank you.

Regards,

Signed up for coverage 3/22/14.

Didn't hear a word from them until 5/6/14, when I received a bill for the month of April. Called to straighten out, not helpful at all. Just told me all the stuff I had to do. No responsibility no assistance. They are going on the wall of shame in my office so others can be warned.

Review: I received a whooping cough vaccine at the written recommendation of my Ob-Gyn due to being pregnant. I was told that I would be reimbursed at 100% for the shot once I called in and produced a doctor's note and a reimbursement form. This was done on April 18, 2014 and I called June 13 to follow up and I was told it was still in process, but that I would be refunded the $63. Yesterday, I called and was told that I would not be refunded the money, and during this time no one called me or sent me a letter, and I spoke to a manger yesterday who basically stated they messed up and made multiple mistakes, but did not offer to refund the money I was promised. I work hard for my insurance benefits and recommended preventative vaccines that might eventually save the company money must be covered for me. The manager admitted that they had notes detailing this entire scenario.Desired Settlement: I want the medical service fully covered like I was told, and the refund check of $63.

Business

Response:

This is a response to the inquiry submitted to your office by [redacted] regarding

the processing of a member submitted claim .

In accordance with the member's benefit booklet , all claim payments are based on Highmark Delaware's allowable charge. Under the member's group PPO plan, immunizations billed for by an out-of-network provider are covered up to 80% of the allowable charge after a $300.00 plan year out-of-network deductible.

Based on a review of the member's complaint, Highmark Delaware management has determined that an exception will be made to reimburse [redacted] for her full cost of the immunization she received on date of service 4118/ 14. An administrative check in the amount of$63.99 will be issued to [redacted] should receive the check within 7-10 business days.

We apologize for the difficulties our member has experienced and we are committed to providing the highest level of service at all times . Should you have any additional questions or concerns, please do not hesitate to contact me.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me.

Review: This complaint is regarding my health insurance company and charges that they should be covering involving my pregnancy and C-section in Feb 2014. My particular plan runs a contract year, not a calender year. We run from June until June and I had a $1200 deductible. I was pregnant last year and I satisfied my $1200 deductible in July or August 2013. The company confirms that I met my deductible last summer. At the beginning of the year, there was what the insurance calls a "computer glitch" in which they inadvertently re-started my plan year in January instead of carrying it through until June. They then proceeded to deny many of the charges for the end of my pregnancy and my C-section in January and February (saying that it should be applied to my deductible). As soon as I noticed these denied charges, I called my insurance company. The representatives would look at my file, note that my plan was re-started inappropriately in January and say that they were "pushing through" a request to fix the "glitch". They even say that it states my deductible has been over-applied, but they won't pay the outstanding charges from the over application. I have been calling at least monthly since February with no success. I now have several laboratories and the hospital with overdue bills. The charges are around $1200 for these facilities.Desired Settlement: It is very simple. I want BCBS to pay all of the outstanding bills to the laboratories and hospital that it should have paid in January and February.

Business

Response:

This is a response to the inquiry submitted to your office by [redacted] regarding claims over-applying to her plan year deductible.

[redacted] has an EPO policy with Highmark Delaware that runs on a June 151 - May 31st plan year. The indiidual deductible for plan year 6/0 1113-05/3 1114 was $1,200.00. The member 's benefits correctly reflected the $1,200.00 individual plan year deductible; however, beginning in January , claims began to apply to the deductible in en-or. The issue was submitted for investigation and it was determined that the system accumulators were incorrectly reset to a calendar year benefit period in error. Our Customer Service Representatives reached out to [redacted] 's billing providers and requested the patient's accounts be placed on hold while we resolved the system issue. We have fixed the system coding to correctly reflect the 06/0 1 -05/31 plan year in the accumulators. At this time, we are expediting the adjustments to the claims that over-applied to the deductible. [redacted] should receive the adjusted claim Explanation of Benefits (EOBs) within 10 to 14 business days.

We apologize for the difficulties our member has experienced and we are committed to providing the highest level of service at all times. Should you have any additional questions or concerns, please do not hesitate to contact me.

Sincerely,

Business

Response:

Thank you for your patience in receive our response to Complaint [redacted]. You will find our reply and resolution to this issue attached.

Review: I had submitted claim #: [redacted] back in September 2014 for diagnostic services for my son. I have contacted BCBS several times, via telephone, to check status and each time I have been told that it has been denied and that I should be receiving a letter in the mail stating what additional information is needed to process the claim. It is now January 2015 and I have NEVER received any such letter. When am I going to be reimbursed for this claim? This claim is for the same treatment and from the same doctor as a previous claim in June 2014.

There is no in-network provider that offers this service therefore I am forced to seek treatment from an out-of network provider. I have been reimbursed for the other claim, so why is this reimbursement taking so long? These funds are needed so that I can continue treatment for my son.Desired Settlement: I need to be reimbursed ASAP. I have already waited 5 months.

Business

Response:

Please find our response in the attached document entitled "Revdex.com case [redacted] response.pdf"

Consumer

Response:

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

Review: This is in regards to a claim not being paid for child service. The date of service was 1/14/2014 at the AI DuPont Children's Hospital in Delaware. I am a Federal Government employee and my insurance policy coves $2500 per calendar year up to age 22. My daughter is 8 years old and the service provided was hearing aids. With absolutely not doubt these are covered under the policy and Highmark Blue Cross continues to deny the coverage. I have called to speak to them 9 times and this issue has not be resolved. I only expect them to pay there share and nothing more. This is beyond despicable and I will stop at nothing to bring this to media attention and my congressman's attention.

The devices (hearing aids) are in full compliance with what is covered per my up to date and paid policy.Desired Settlement: I want them to pay the claim that they are obligated to pay. I would like to cancel this policy also as I want nothing to do with criminals who steal from me or my family.

Business

Response:

This is a response to the inquiry submitted to your office by [redacted] regarding a claim for hearing aid services rendered by A.I. DuPont Children's Hospital, on date of service 1/14/14 for his daughter.

Highmark Delaware administers the benefits for the FEP plan. The member's benefit plan states benefits are available for hearing aid services as follows :

Covered Hearing Aid Revenue Codes

The Hearing A id Revenue Codes listed in Chart B will process as covered DME services subject to appropriate hearing aid

benefit maximum per ear per time period. Chart B - Hearing Aid Revenue Codes Code Narrative

0470 General

0471 Diagnostic

0472 Treatment

0479 Other Audiology

The Member does have benefits for hearing aid services when billed by the above referenced facility with the revenue codes above. The provider of services has billed with Revenue Code 292, which is not listed as a covered service under the benefit plan. Highmark Del aware h as contacted the provider's billing office on behalf of the member on 4/ 17/ 14 and advised the provider that a corrected claim is needed .

Should you h ave any additional questions or concerns, please do not hesitate to contact me.

Review: My 20 year old daughter had knee surgery on November 1, 2013. The surgeon prescribed that she rent a knee machine and accessories from [redacted] Orthopedics. The technician brought the machine to my home and called BC/BS from my home to confirm that this was a covered service. We were told it would be covered at 100% ). [redacted] also spoke to [redacted] in the BC office that day and was told no authorization was required (I can provide the call reference #s if needed). This claim was denied and [redacted] was told they were "not a contracted provider" on that date (although they were on the following day). They were also unable to appeal the claim for the same reason. I attempted to appeal this decision but could not because my daughter was over 18. She signed a form giving me permission to take care of this and it was faxed to BC/BS. They did not receive it and I had to send another copy. I spoke to several people in that time period. Eventually they received the permission form but I was told they could not accept my appeal because it was out of the window of appeal time. I have made multiple phone calls to straighten this out. I have been promised that I would receive a copy of the written denial (still haven't gotten it). I was told a supervisor would call me. (Didn't happen). I called again in early June and a supervisor called me back. I missed his called and called him back. He didn't answer but left me a vm. I called him back but never heard again. This has been a mess since the beginning and I am shocked that it all occurring over a $288 claim. Again, we were told clearly that this would be paid. I know that your phone message offers a disclaimer about info but we can only depend on what we are told. Because of all the difficulty there were some time breaks between calls and attempts but you can see that I was in touch with your company through.Desired Settlement: It is my hope that the claim to Synergy will be renewed and paid. I am happy to provide any needed documentation. I have copies of letters, forms, phone call reference numbers and notes. I appreciate any help that can be provided in having this handled.

Business

Response:

Please refer to the uploaded response in PDF format.

Consumer

Response:

Review: Before signing up for their health care coverage, I was directed by a representative to their website to a page of covered medicines to confirm how much my medicines would cost under the selected plan. ([redacted]hen to "Find a Doctor or RX" then to "Find a Drug" then to "Progressive Formulary," which takes you to this page [redacted] This information was critical for me in deciding what plan to go with and to go with their services and this information was very incorrect. At the time of singing up for this health coverage I had the representative confirm verbally for me that the prices would as they are stated, that I understood the charts. Once again, this information was deceitful. The information on the website listed specific medicines as being covered under the cheapest tier ($8 co pay), which were not and in actuality cost over $90. Other medications that were on this website described as being on a higher tier, which would mean that I would pay $90, weren't covered at all and cost me at the pharmacy well over $200. Upon calling to complain I was told that I could not switch plans even as the information I was given at the time--the information they provided me with to sell me the plan--was a lie.Desired Settlement: I want this company to live up to their initial offering, to cover the medicines to the prices that they initially advertised.

Business

Response:

This is in response to your inquiry sent to us on behalf of member identified by the Case ID number you provided.

The member states intheir complaint that they compared prescription medication pricing prior to obtaining coverage through the [redacted] but does not state which medications and dosages they inquired about.

Highmark has researched the member's prescription claims, and have determined all claims have processed correctly in accordance with the member's benefits. The member should work with their ordering physician and pharmacist to verify the pricing of his medications, as different forms of the same medication may be classified differently.

If the member wishes to inquire about changing plans, they should contact the [redacted] at **

Review: I have two issues pending.

1- I have been trying to get reimbursed for a claim mailed back on June 18, 2014. It went to appeals on 9/4/2014 and has since been approved. However, here we are two months later and I still have not been reimbursed. Every time I call customer service I am told I should receive the check in 7-10 days. It has now been FIVE months and I still have not been reimbursed. This money is needed, so that I can continue services for my son.

2- I submitted a claim on 9/15/14 to be reimbursed for eyeglasses, only to receive an EOB that states the provider is out of network. This provider is indeed in network! BCBS mailed me a check for a $1 which is what they cover for out of network services. However, they did pay for the eye exam from the SAME provider on the same day I paid out of pocket for glasses. Each time I call customer service I get a different answer. I have been told I do not have vision coverage, put on hold and then told "Oh, yes you do". I have phoned three other times and each time I am told it is being adjusted, wait 7-10 days for a check.Desired Settlement: I would like to be reimbursed ASAP.

Business

Response:

Attached is the response for [redacted]

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me.

Worst insurance I have had in 53 years. I spend 10K+ per year they continually get our information wrong no matter how many times we correct it and deny claims. I have spent more time in the last 2 years managing this plan then the last 30 years combined.

Review: I was sold a policy in December and I made sure that my vasectomy that I was planning on having was covered. I was assured that the it was by the sales rep. When I went to have my vasectomy I ensured that the provider was in network. After receiving my vasectomy I got a bill stating that it was no covered under my policy. After a lengthy conversation highmark tried to say that we changed the policy since our 2014 policy which would have been covered. Highmark states unless we have a date, time and name of their sales rep they can not cover it. They also tried to say I was not on the policy when I was the policy holder. I pay my bill every month through auto payment so there should be no issue there. I have a feeling that this is a bait and switch.Desired Settlement: As promised, I want my vasectomy covered per the policy I had in 2014. I did not authorize a change in my policy and I was assured by the sales rep that it was cover. I appologize that I can not remember a date time and the name of the sales rep from 8 months ago.

Business

Response:

Please find Highmark Blue Cross Blue Shield Delaware's response attached.

Review: Highmark cancelled my policy due to non-payment regardless of the fact that it was on auto-pay. The payment was to be charged to my credit card, but due to a security breach, which happens quite frequently now, [redacted] issued a new card. I had no idea that the payments were not going through until I got a letter cancelling my policy. I put these types of recurring bills on auto-pay so that I don't have to manage such accounts and expect proper notification when a payment doesn't go through. The same credit card was being used for [redacted], and other recurring services, and when the payment didn't go through for those services, I received phone calls and e-mails that alerted me to change the credit card number. I received no such notices from Highmark. After my new credit card was issued, I had no problems with any other autopay services excepting Highmark. Now, Highmark refuses to reinstate my policy and allow me to pay for the unpaid 2 months and pay with the new credit card moving forward.Desired Settlement: I want Highmark to reinstate my policy without any further re-application due on my end. I have already changed the credit card number on the website and have already requested to be able to pay for the past months when they tried to charge the previous credit card.

Business

Response:

Please find the response from Highmark Pennsylvania attached.

Review: I have had lumbar nerve blocks in the past with no problems but last year I had two done in November of 2014. During the same month of November I received a check ($384.12) from Highmark which never happened before so I called and told them that the check is payment is supposed go to the provider. They informed me to just destroy the check and they would take care of it. In January I started receiving a bill from Outpatient Anesthesia Specialists PA in the amount of $384.12. I've received the same bill many times through the past year and called Highmark many times and was assured it would be taken care of. I just received the bill again threatening collections on July 31, 2015. I called highmark again and am still getting the run around. We're well into 9 months with this issue and I'm tired of wasting hours upon hours of my time without any resolve.

My husband ([redacted]) is the member who carries the insurance. Member ID: [redacted]Desired Settlement: Pay the bill you are required to pay so it doesn't go to collections because of your mistakes.

Business

Response:

RE: Revdex.com of Delaware Response to Complaint # [redacted]Please find attached Highmark Blue Cross Blue Shield of Delaware's response to this complaint.Thank you.