UPMC Health Plan

RE: Complaint I* #***ear Ms***:UPMC Health Plan, inc("UPMCHP") has receive* an* reviewe* your letter *ate* May 5,2017, as well as the accompanying complaint,We thank you for bringing this matter to our attentionUPMCHP takes all potential privacy an* security concerns very seriously,
an* is currently investigating the possible occurrence of theinci*ent *escribe* in the complaintShoul* results of the investigation substantiate the concerns expresse* by the complainant/ UPMCHP will contact the complainant *irectly regar*ing any implicate* resolution,.If you have any further questions or nee* a**itional information, please *o not hesitate to contact me at ###-###-####.Respectfully Submitte*,Cha* *, Greenwal*UPMC Health Plan***

Re: Complaint No***Dear Ms***:UPMC Health Plan, Inc, (“UPMCHP”) has received and reviewed your letter dated December 29, 2016, regarding the member’s additional concerns in connection with the referenced complaintPlease accept the following as UPMCHP’s response to those concerns.In her initial letter, the member sought reinstatement of her federally facilitated (FFM) UPMC EPO Silver plan which she complained had been terminated without noticeIn UPMCHP’s December 22, response, we explained that the members coverage was terminated due to a series of unpaid balances dating back to September 2016, and following an October written notice and a reminder call on November 15, Upon investigating the member’s complaint, however, UPMCHP determined that due to an error with the member enrollment system, the member was not sent a termination warning letter in November As a result this error UPMCHP offered to reinstate the member if she satisfied her account balance in full.The member confirms in her follletter that UPMCHP contacted her regarding the offer of reinstatement and states that she paid her account balanceThe member complains, however, that as of December 28, her coverage had not been reinstatedUpon investigation, the member’s coverage was reinstated as of December 28, following her call to UPMCHP, and her pharmacy was able to submit her claim.In addition, on December 29, 2016, a UPMCHP representative called the member and advised that her plan was due to terminate on December 31, and that she was not automatically enrolled for coverage because her plan was inactive at the timeUPMCHP advised member that if she wished her coverage to continue, she would need to contact the FFM to enroll and request a January 1, start date.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 ** J*** EsqUPMC Health Plan Legal Services Department

RE: Complaint ID ***Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated July 22,2017, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization- that would allow UPMCHP to disclose protected health
information, Without a HTPAA-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 A*** Staff Attorney UPMC Health Plan

Re: Complaint No*** by *** ** ***Dear Ms***UPMC Health Plan, Inc(‘'UPMCHP”) has received and reviewed your letter dated November 21,2016, as well as the accompanying complaint submitted by *** ** ***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*** 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 ** J***
UPMC Health Plan
Legal Services Department

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
Re; Complaint ***Mrs***,In response to UPMC response to my complaint, I am not sure how it was taken out of context from a complaint against UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA to UPMC Health Plan legal H1PAA and PHI.First of all, I was not requesting anyone's personal information or medical records from UPMCMy complaint was against against UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA for sending junk mail [advertisements] to my home for people that don't live at my home and never have lived at my homeThe names are Irene *** and *** * *** ***Once again UPMC for Life at U.SSteel Tower 9th Floor Grant Street Pittsburgh PA needs to stop sending me advertisements for an Irene *** and *** * *** ** at my address [above]No such people have ever lived at my house.Sincerely, *** ***

RE: Complaint ID ***Dear Ms, ***.UPMC HealthPlan, Inc("UPMCHP") has received and reviewed your letter dated July 1, 2017, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-compIaint 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 A*** Staff Attorney UPMC Health Plan

RE: Complaint ID ***Dear Ms*** ***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 17, 2016, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HJPAA-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 complaint, UPMCHP Member Services will be outreaching directly to the complainant today or tomorrow regarding the issues raised in the complaint.Thank you for bringing this matter to our attention.Sincerely,Matthew S*Staff AttorneyUPMC Health Plan - Legal Services Department

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me. I also want to thank the Revdex.com for helping in coordinating this problem.You have done a very excellent job with all of the problems that I have experienced.Thanks again,*** *** *** ***

RE: Complaint ID ***Dear Ms***:UPMC Health Plan, Inc("UPMCHP") has received and reviewed your letter dated October 17, regarding Complaint ID ***.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health
informationWithout a HIPAA-cornpIaint 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 A*** Staff Attorney UPMC Health Plan

Re: Complaint ID: [redacted]Dear Ms. [redacted]: UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed the abovecaptioned complaint dated October 13, 2015. 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 UPMCHP. In this instance, the services were not covered based on the nature of the claims submitted by the complainant’s provider. However, 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 attention. If 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.Re; Complaint [redacted]Mrs. [redacted],In response to UPMC response to my complaint, I am not sure how it was taken out of context from a complaint against UPMC for Life at U.S. Steel Tower 9th Floor 600 Grant Street Pittsburgh PA 15219 to UPMC Health Plan legal H1PAA and PHI.First of all, I was not requesting anyone's personal information or medical records from UPMC. My complaint was against against UPMC for Life at U.S. Steel Tower 9th Floor 600 Grant Street Pittsburgh PA 15219 for sending junk mail [advertisements] to my home for people that don't live at my home and never have lived at my home. The names are Irene [redacted] and [redacted] [redacted]Once again UPMC for Life at U.S. Steel Tower 9th Floor 600 Grant Street Pittsburgh PA 15219 needs to stop sending me advertisements for an Irene [redacted] and [redacted] [redacted] at my address [above]. No such people have ever lived at my house.
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.  For your reference, details of the offer I reviewed appear below.Initially in September of 2014 when I wrote tp UPMC for LIfe U.S. Steel Tower 9th floor 600 Grant street Pittsburgh PA 15219 the advertisments for [redacted] and [redacted] stopped for about a year. Then they started coming again and when I file a complaint with the Revdex.com it becomes a Hippa issue. I consider this harrasment. All they are are advertisements for people that UPMC probably just made up and as far as I am concerned can lead to fraud. How can I get a HIPPA release form signed by some individual that moree than likely does not exist? No such people have ever lived at my addreess and I did not start getting these until after I lived here for years.
Regards,
[redacted]

Rc: Complaint No. [redacted] by [redacted]Dear Ms. [redacted]:
UPMC Health Plan, Inc. ("UPMCHP”) has received and reviewed your letter dated January 15, 2015, as well as the accompanying complaint submitted hy [redacted].In his complaint, Mr. [redacted] complained...

regarding a $10 CVS gift card issued to non-Membens who requested information from UPMCHP regarding UPMC for Life Medicare products. Mr. [redacted] attempted to use his card for the purchase of L’Oreal face cream but was informed by CVS that the gift card could not be used toward his purchase of L’Oreal face cream.UPMCHP engaged CVS to provide “health related" gift cards to prospective members. At the time, the “health related" gift cards were the only gift cards offered by CVS that excluded alcohol and tobacco products. Unfortunately, UPMCHP had no additional discretion about the items that were included or excluded. A copy of the CVS flier provided with the health related gift cards is attached hereto. While the flier does indicate “Skin Care" is a permissible product, the L’Oreal skin cream at issue is considered by CVS to be a cosmetic product.We apologize for any inconvenience this matter has caused Mr. [redacted]. UPMCHP considers input from members to be a valuable source of information in helping us achieve our commitment to ensuring quality care and service tor our members, and apologizes for any dissatisfaction that Mr. [redacted] may have experienced. UPMCHP has provided feedback regarding the flier and restrictions on use to CVS. UPMCHP considers this matter to be resolved to the best of its ability.Thank you for bringing this matter to our attention. If you have any further questions or need any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,[redacted], 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.UPMC did contact me directly so as not to violate my privacy as it relates to healthcare or health insurance issues. UPMC did address my complaint in their internal response as well as they the letter sent in response to the Revdex.com complaint. They admitted customer service representative on Dec. 15th, 2017 lacked clarity in answering my questions about the ramifications of non-payment of premiums. UPMC also offered in their original internal response to reinstate coverage for 2018 if past due premiums were paid for 2017. But both of those things happened prior to my submitting my complaint to the Revdex.com. UPMC's staff attorney sent me a letter which I received shortly after the one sent to the Revdex.com about this matter. The letter reiterates UPMC's admitting lack of clarity on the issue and the offer to reinstate coverage if 2017 premiums were paid. However, the deadline to comply with that resolution had passed and I was unable to may payment prior to it. Thus, barring any further review by UPMC or a directive from any outside agency such as the FMM or the PA Department of Insurance or through legal means, I remain without 2018 coverage. I appreciate both the admission of lack of clarity and additional time given for reinstatement if past due payments were made to UPMC. However,  I have continuing issues with UPMC on the matter including the publishing of marketing piece that is contrary to the reality of UPMC's actual rules and guidelines, continuing pattern of misleading, incorrect and ever changing information when talking to a CSR one day and then going over the same issue or issues with another CSR and being told something completely different. I also have issue with UPMC and the FMM website presenting contrary information on the subject of grace periods while the issue was unfolding. However, it appears that both UPMC and the FMM website now present similar information on the subject. I also have issue with UPMC as to when they inform past due customers as to the ramifications of non-payment for a new policy year. Additionally, I have issues with how the complaint process works at UPMC such as not having an email address to submit documents, clear information on deadline to submit documents as well as not receiving clear information on how many levels of internal appeal UPMC offers and clear information about the availability of transcripts of customer service calls if requested by a consumer. Most of these matters have been presented in a complaint filed with the PA Department of Insurance and may be filed with the FMM.
Regards, [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.  For your reference, details of the offer I reviewed appear below.
11/8/2017 I received a response dated November 6, from UPMC attorney Ariell A[redacted], stating that their UPMC member services placed me on the do not call list on October 26.   This was per my repeated requests which was not made clear in the letter.  This does not address the problem.  I was called, at the end on a daily basis,  from Maxim health which is affiliated with UPMC.  I repeatedly told them I do not need their services.  The calls only increased to an automated system.  I requested UPMC to stop calling me.  That did not work until October 26th.  When I called UPMC again to stop the calls.  So the issue is Maxim Health Care and UPMC giving my information.  And Maxim having an aggressive sales campaign that I could not stop without much effort on my part. My effort should not have been needed.  The calls border on harassment and need to be addressed with Maxim Health Care.  And, this was not addressed in the letter.  In fact it was stated that now that I was on the DO NOT Call list the problem was solved.  [redacted]

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 products. As you know, UPMC Health Plan was unable to offer a detailed response to Mr. [redacted]’s complaint in the absence of a HIPAA compliant authorization. As such, a letter was sent to Mr. [redacted] that addressed his concerns. Once received, we believe Mr. [redacted] should be satisfied with the outcome. We 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 attention. Should you have any questions or require any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Laura N.K. Miller Associate Counsel

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 information. Without 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 complaint. On 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 attention. If you have any further questions or need any additional information, please do not hesitate to contact me at ###-###-####.Sincerely,Stacey ** 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 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 levels. According 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 center. As a result, UPMCHP originally processed the claim as non-emergent and paid at the lower benefit level. After 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 deductibles. The payment should process within two business days of the date of this letter.UPMCHP apologizes for the inconvenience to this member. Should you have any questions or concerns, please do not hesitate to contact me.Sincerely,
Matt S[redacted]
Staff Attorney
UPMC Health Plan

Dear Ms. Palmer Edwards:UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter of February 1,2018, as well as the accompanying complaint filed by [redacted] at the above-captioned file number.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-complaint 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 attention. Should you have any questions or require any additional information, please do not hesitate to contact me at [redacted]UPMC Health PlanSincerely,Lakshmi D[redacted] 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. [redacted]’ complaint was not accompanied...

by a HIPAA compliant authorization to disclose PHI. As such, UPMC Health Plan has responded to Mr. [redacted] directly regarding his complaint.Thank you tor bringing this matter to our attention. If you have any further questions or need any additional information, please do not hesitate to contact me at [redacted].Sincerely,Laura [redacted]. M[redacted], Esquire Associate Counsel