UPMC Health Plan

RE: Complaint ID [redacted] Dear Ms [redacted] UPMC Health Plan, inc("UPMCHP") has received and reviewed your letter dated April 4, 2017, regarding; Complaint ID [redacted] .The above-ieferenc'ed complaint didnot include a HIPA A authorization that would allow UPMCHP to disclose protected health informationWithout a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,John S [redacted] Staff Attorney UPMC Health Plan

Dear Ms [redacted] :UPMC Health Plan, Inc, (“UPMCHP”) has received and reviewed your letter of May 19, 2015, as well as the accompanying complaint filed by a UPMCHP member at the above- ’captioned file numberIn accordance with the directions included in your letter, this response will not personally identify the member.The member's complaint concerns the fact that she was provided inaccurate information regarding whether a particular procedure was covered under her benefit planBetween July and September of 2013, the member contacted UPMCHP on several occasions to inquire as to whether a [redacted] reversal was covered under her planInitially, the member received incorrect information from a Member Services representative and was told that the procedure was a covered benefitPrior to the member receiving the procedure, both she and her provider were advised that the procedure was actually excluded from coverage based on her plan benefitsUPMCHP apologizes for any confusion and inconvenience caused by the incorrect information provided and has taken appropriate steps to provide additional training to the Member Services representative involvedHowever, because the requested procedure is not a covered benefit, the member was ultimately provided with correct information about her benefits, and she did not receive the procedure in reliance on the incorrect information, we are unable to cover the service.The member also disputes her cost-sharing for other services received on August 2, and August 22, UPMCHP has reviewed the dates of service in question and has confirmed that the member was billed correctly in accordance with her coverageOn August 2, the member incurred a $copay for visiting a specialist, which is the standard copayment amount under her planShe was also charged $98.45, which applied to her deductible, for services received on August 22, Because the claims for these dates of service were processed correctly and the member received the services in question, we are unable to provide reimbursement for this cost-sharing"Thank you for bringing this matter to our attentionShould you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely [redacted] Esq

RE: Complaint ID # [redacted] Dear Ms, [redacted] :UPMC Health Plan, Inc, ("UPMCHP") has received and reviewed your letter dated January 4,2018, as well as the accompanying complaint.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health informationWithout a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint, However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any further questions or require additional information, please do not hesitate to contact me at ###-###-####.Respectfully Submitted,Chad *G [redacted] UPMC Health Plan

RE: Complaint ID [redacted] Dear Ms [redacted] :UPMC Health Plan, Inc(UPMCHP) has received and reviewed your letter dated June 3, 2016, as well as the underlying complaint filed with ID of 11470374The UPMCHP member at issue was a member of a PPO plan with separate in-network and out-of-network benefit levelsAccording to the complaint, the member received an emergency appendectomy at [redacted] Hospital on October 4, 2015, and UPMCHP paid the claims from that procedure at the lower, out-of-network benefit level.UPMCHP has reviewed the complaint and determined that [redacted] Hospital incorrectly billed the procedure as an ambulatory procedure occurring at an ambulatory surgical centerAs a result, UPMCHP originally processed the claim as non-emergent and paid at the lower benefit levelAfter reviewing the file, UPMCHP has reprocessed the claims as emergency services, and UPMCHP will pay the claims at the higher, in-network benefit level, subject to the applicable in-network copayments and deductiblesThe payment should process within two business days of the date of this letter.UPMCHP apologizes for the inconvenience to this memberShould you have any questions or concerns, please do not hesitate to contact me.Sincerely, Matt S [redacted] Staff Attorney UPMC Health Plan

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 [redacted] ***November 20, 2015Revdex.com [redacted] ***Re; Complaint [redacted] Mrs [redacted] ,I got an email about a response from UPMC about my complaint and I responded rejecting their response.A little while later I received a letter from UPMC that is acceptable and I would like to now dose the complaintThank you.Sincerely, [redacted] ***

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint I've attached the HIPPA authorization Regards, [redacted]

Re: [redacted] Complaint ID: [redacted] Dear Ms [redacted] :UPMC Health Plan, Inc(“UPMCHP'’) has received and reviewed your letter of January 14,2016, as well as the accompanying complaint tiled by [redacted] at the above-captioned file number.Mr [redacted] complains about the denial of reimbursement for medicationMr [redacted] has prescription drug coverage under the UPMCHP [redacted] UPMCHP established prior authorization requirements and quantity limits on certain medications to comply with Food and Drug Administration guidelines and to encourage appropriate prescribing and use of such medicationsOur records show that Mr [redacted] repeatedly attempted to fill a prescription for [redacted] on September 3, through October 19, Coverage was denied because [redacted] requires prior authorizationOn November 2, 2015, UPMCHP received medical records demonstrating that as of October 27, 2015, Mr [redacted] met the prescribing criteria, and the requested medication was approved indefinitelyUPMCHP attempted to contact Mr [redacted] by telephone on November 4, 2015, to inform him that the authorization was approved effective November 2, 2015, but was unable to reach himUPMCHP backdated the authorization to October 27, (the day Mr [redacted] was found to meet criteria for approval).On November 19, 2015, Mr [redacted] contacted UPMCHP requesting reimbursement for out of pocket expenses incurred up to the date of approvalA UPMCHP representative provided him with instructions to file a claim.A claim for reimbursement was received on December 16, 2015, for dates of service commencing on October 5, However, because this date of service was before October 27, 2015, the request was denied.While UPMCHP is sympathetic to Mr [redacted] ’s complaint, UPMCHP is unable to reimburse him for medication purchased prior to meeting the medical necessity guidelines, which in this case, include the required screening performed on October 27, 2015.Thank you for bringing this matter to our attentionShould you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely,Nancy [redacted] F [redacted] Esq.UPMC Health Plan

Rc: Complaint No [redacted] UPMC Health Plan, Inc, ("UPMCHP") has received and reviewed your letters dated September and 30, 2014, as well as the accompanying complaint submitted by [redacted] a consumer in Western Pennsylvania and non-member of any UPMCHP product ("Consumer') In his complaint, Mr [redacted] complained that UPMCHP mailed an UPMC for Life Medicare marketing booklet addressed to his deceased mother at his, presumably, home addressMr [redacted] also expressed discontent with UPMC for Life's use of certain data sources to identify individuals potentially eligible for enrollment in UPMCHP's Medicare products By way of this complaint, Consumer did not provide his mother’s nameWithout her name, UPMCHP is unable to locate a history of any calls Consumer may have had with UPMCHP's Member Services Department or to affirmatively remove her name from UPMCHP’s marketing listsAlthough the name of his mother is not available in this complaint, UPMCHP will use its best efforts to remove Consumer’s address from UPMCHP’s marketing lists Regarding the Consumer's concerns about UPMCHP's use of certain data sources, UPMC for Life's mailing lists are compiled through the engagement of a [redacted] approved vendorAll UPMC,/or Life marketing, including the use of CMS approved vendors, is in compliance with CMS guidelines and regulations We apologize for any inconvenience this matter has caused the ConsumerUPMCHP considers input from members to be a valuable source of information in helping us achieve our commitment to ensuring quality care and service for our members, and apologizes for any dissatisfaction that Consumer may have experiencedIf the Consumer wishes to provide his mother’s name, UPMCHP will use its best efforts to remove her name from all further marketing listsIn the meantime, a similar attempt has been made wilh regard to Consumer’s address and UPMCHP considers this matter to be resolved lo the best of its ability Thank you for bringing this matter lo our attentionIf you have any further questions or need any additional information, please do not hesitate to contact me at ###-###-####

Re: Complaint No [redacted] by [redacted] ***Dear Ms [redacted] UPMC Health Plan, Inc(‘'UPMCHP”) has received and reviewed your letter dated November 21,2016, as well as the accompanying complaint submitted by [redacted] ***.The above-referenced complaint did mot include a HIPAA authorization that would allow UPMCHP to disclose protected health informationWithout a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint.Please be advised that UPMCHP has diligently and thoroughly investigated the subject matter of this complaintOn December 2, 2016, UPMCHP Member Services sent a letter directly to Mr [redacted] regarding the issues raised in his complaint.Thank you for bringing this matter to our attentionIf you have any further questions or need any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Stacey [redacted] J [redacted] UPMC Health Plan Legal Services Department

RE: Complaint ID [redacted] Dear Ms [redacted] :UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 27,regarding Complaint ID [redacted] .The above-referenced complaint did notinclude a HIPAA authorization that would allow UPMCHP to disclose protected health informationWithout a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaintHowever, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly to the affected individual with a more detailed response.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Ariell Antonio Staff Attorney UPMC Health Plan

Re: Complaint No [redacted] by [redacted] Dear Ms [redacted] :UPMC Health Plan, Inc, ("UPMCHP”) has received and reviewed your letter dated November 24, 2015, as well as the accompanying complaint submitted by [redacted] ***.Mr***’ complaint was not accompanied by a HIPAA compliant authorization to disclose PHIAs such, UPMC Health Plan has responded to Mr [redacted] directly regarding his complaint.Thank you tor bringing this matter to our attentionIf you have any further questions or need any additional information, please do not hesitate to contact me at [redacted] .Sincerely,Laura ***M***, Esquire Associate Counsel

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below Regards, [redacted]

I received a letter in the mail in January from UPMC offering me a $gift card for going online and taking the healthcare assessment and choosing a PCP I did this, but I never received my gift card I sent a message online to complain, and I received a response saying I never chose my PCP I responded and said I did and could see the PCP name on my homepage, but I gave it to them again anyways I asked if I was still receiving the gift card and was told to contact [redacted] I sent another email complaining about not receiving the gift card I was promised, and this time I was told I was not eligible because I have Medicaire UPMC and the gift card was only eligible for regular plan members Why did they send me the offer in the first place if I was not eligible? And why did the other rep not tell me this? I feel like they just wanted an excuse to not pay me the gift card I'm disappointed in the customer service

Re: Complaint ID: [redacted] Dear Ms [redacted] : UPMC Health Plan, Inc(“UPMCHP”) has received and reviewed the abovecaptioned complaint dated October 13, Pursuant to the directions included in the letter, this response will not personally identify the member.The complaint sets forth lhat the complainant, received diabetic education services on July 8, 2015, and is upsett that these services were not covered by UPMCHPIn this instance, the services were not covered based on the nature of the claims submitted by the complainant’s providerHowever, UPMCHP is working with the provider on getting a proper claim submitted, and will contact the complainant directly regarding the outcome.UPMCHP values the satisfaction of its membership, and we thank you for bringing this matter to our attentionIf you have any further questions or need additional information, please contact me at ###-###-####.Sincerely, [redacted] Esq UPMC Health Plan

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below Regards, Megan Walker

Re: Complaint No [redacted] by [redacted] ***Dear Ms [redacted] :UPMC Health Plan, Inc(“UPMCHP”) has received and reviewed the letter submitted by David [redacted] on November 20,2015.UPMC Health Plan's response to the Revdex.com was on behalf of its UPMC for Life Medicare Advantage productsAs you know, UPMC Health Plan was unable to offer a detailed response to Mr***’s complaint in the absence of a HIPAA compliant authorizationAs such, a letter was sent to Mr [redacted] that addressed his concernsOnce received, we believe Mr [redacted] should be satisfied with the outcomeWe are happy to share a copy of the letter sent to Mr [redacted] with the Revdex.com should Mr [redacted] sign a HIPAA compliant authorization to do so.Thank you for bringing this matter to our attentionShould you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####Sincerely,Laura N.KMiller Associate Counsel

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below Hello, In accordance with the letter received I am updating you on recent contact with UPMC Health plan.On 12/21, I received a call from their “800” number.I was told that because of a “glitch” in the system and failure to notify me.That I did not have insurance, that it had been cancelled, I would be reinstated.My reference number for this was [redacted] In order for the reinstatement to be completed I would need to make December paymentWhich I did, $275.58, confirmation number for that [redacted] I held on the line while I was reinstated, or thoughtToday, 12/28, I went to the pharmacy.No insurance.Please call UPMC, which I did and was told I was never reinstatedAnd it was denied.(the reinstatement)So, now I am out two payments of $And have yet to be formally notified that I do not have coverageIs this for real? Sincerely, [redacted] ***

RE: Complaint ID [redacted] Dear Ms [redacted] OnApril 18, UPMC Health Plan, Inc, ("UPMCHP") responded to an initial complaint filed by Mr [redacted] That complaint did not include a HIPAA authorization that would have allowed UPMCHP to disclose protected health information, Without a HIPAA-compIaint authorization, UPMCHP advised that it was unable to provide a response to the Revdex.com regarding the complaint.On April 21, 2017, UPMC Health Plan, Inc("UPMCHP") received a fax sent by Mr [redacted] concerning UPMCHP's responseAlthough Mr [redacted] provided an authorization form with his April fax, he did not provide UPMCHFs required authorization and release formIn an April 24-letter, UPMCHP attached a copy of the proper form for Mr [redacted] to fill out, sign, and submit if he desired, UPMCHP did not receive a completed copy of the correct form.UPMCHP has received your letter dated May regarding Mr [redacted] , Again,UPMCHP does not have a proper HIPAA authorization that would allow UPMCHP todisclose protected health information, Without a HIPAA-compIaint authorization,UPMCHP is unable to provide a response to the Revdex.com regarding the complaint.Should you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,John S [redacted] Staff Attorney UPMC Health Plan

RE; Complaint ID [redacted] Dear Ms, [redacted] :On April 21,2017, UPMC Health Plan, inc("UPMCHP,f) received a fax sent by Mr [redacted] concerning UPMCHP's response to Complaint ID [redacted] .As explained in UPMCHP's April response, without a HlPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint.Although Mr [redacted] provided an authorization form with his April fax, he did not provide UPMCHP's required authorization-and release formWe have attached a copy of that form for Mr, [redacted] to fill out, sign, and submit if he desires.Should you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,John S [redacted] Staff Attorney UPMC Health Plan

RE: Complaint ID [redacted] Dear Ms [redacted] :UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated; November 22, regarding additional concerns in connection with Complaint ID [redacted] ’As explained in UPMCHP's initial response dated November 3, 2017, without a HIPAA compliant- authorization form UPMCHP is unable provide a response to the Revdex.com regarding this complaintWe have attached a copy of that form for MsBattaglia to fill out sign, and submit if she desires.Should you have any questions or require any additional information, please do not hesitate to contact me at [redacted] Sincerely,Ariell A [redacted] Staff Attorney UPMC Health Plan