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 18 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 21 fax, he did not provide UPMCHP's required authorization-and release form. We 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

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]

February 21,2018Via Fax 412-922-8656 [redacted] Revdex.com Serving Western Pennsylvania 400 Holiday Drive, Suite 220 Pittsburgh, PA 15220RE: Complaint ID #[redacted]Dear Ms, [redacted]:UPMC Health Plan, Inc, ("UPMCHP") has received and reviewed your letter dated February...

11,2018, as well as the accompanying complaint.The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HTPAA-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 attention. Should you have any further questions or require additional information, please do not hesitate to contact me at [redacted].Respectfully Submitted,Chad *. G[redacted] UPMC Health Plan

RE: Complaint ID [redacted]Dear Ms. [redacted]:UPMC Health Plart, Inc, ("UPMCHP") has received and reviewed your letter dated October 17, 2017 regarding Complaint ID [redacted].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 ###-###-####.Sincerely,Ariell A[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 January 31,2017, regarding Complaint ID [redacted].The complainant in question stated that an operational error had prevented his application and payment for his daughter's...

2017 health insurance plain from being processed correctly, leaving his daughter temporarily uninsured.In addition to reaching out to your office, the complainant also reached out directly to the Federally Facilitated Marketplace (also known as the healthcare.gov "Exchange"), which makes eligibility determinations regarding individuals who enroll in health insurance through the Exchange.The Exchange forwarded the complaint to UPMCHP, which determined based on the information provided that the complainant's daughter was eligible to have coverage reinstated back to January 1,2017. On February 1, UPMCHP reinstated her insurance plan, effective retroactively to January 1.  UPMCHP considers this matter fully resolved, and we apologize for any inconvenience to the complainant or his family.Thank you for bringing this matter to our attention.Sincerely,Matthew S[redacted]Assistant CounselUPMC Health Plan

Rc: Complaint No. [redacted]
UPMC Health Plan, Inc, ("UPMCHP") has received and reviewed your letters dated September 10 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 address. Mr. [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 name. Without 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 lists. Although 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 vendor. All 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 Consumer. UPMCHP 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 experienced. If the Consumer wishes to provide his mother’s name, UPMCHP will use its best efforts to remove her name from all further marketing lists. In 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 attention. If you have any further questions or need any additional information, please do not hesitate to contact me at ###-###-####.

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.
The response from UPMCHP (the health plan) does not provide an explanation of where my overpayments are.  They refuse to provide a record of payments and I have no way to get them to give this to me.  As long as they are allowed to hold my money hostage and pretend to be confused about which entity of UPMC is holding my money, they will.  The only way to resolve this complaint is for UPMC to provide me with a list of payments and where the payments I have made have been applied- exactly.  To which hosptial, which bill, which encounter, etc.  Otherwise, they can continue to hold my money hostage under the guise that I actually owe it to them.  I may have outstanding payments- but I'm really not sure.  I'm  not paying bills that do not include histories of past payments, etc. because they keep holding my overpayments and saying that I owed them- but won't produce records of payments, bills, etc.
Regards,
[redacted]

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

RE: Complaint ID [redacted]Dear Ms. [redacted]On. April 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 response. Although Mr. [redacted] provided an authorization form with his April 21 fax, he did not provide UPMCHFs required authorization and release form.. In 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 10 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

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 complaint.Thank you.Sincerely,[redacted]

RE; Complaint ID [redacted]Dear Ms. [redacted]:On December 21, 2017 UPMC Health Plan, Inc. ("UPMCHP") received additional correspondence concerning UPMCHP's response to Complaint ID. [redacted]'Although an authorization form was provided with the December 21st correspondence, it did not contain the signature of the individual who is the subject of the complaint. As such, without a HIPAA-complaint authorization, UPMCHP is unable to provide a response to the Revdex.com regarding this complaint.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 ###-###-#### or Gail M[redacted], Administrative Assistant, at ###-###-####.Sincerely,Ariell A[redacted] Staff Attorney UPMC Health Plan

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 medication. Mr. [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 medications. Our records show that Mr. [redacted] repeatedly attempted to fill a prescription for [redacted] on September 3, 2015 through October 19, 2015. Coverage was denied because [redacted] requires prior authorization. On 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 indefinitely. UPMCHP 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 him. UPMCHP backdated the authorization to October 27, 2015 (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 approval. A 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, 2015. 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 attention. Should you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely,Nancy ** F[redacted] Esq.UPMC Health Plan

Re: Complaint No. [redacted] by David [redacted]
Dear Ms. [redacted]:UPMC Health Plan, tnc, ("UPMCHP") has received and reviewed your letter dated August 31, 2015, as well as the accompanying complaint submitted by [redacted].Mr. [redacted]'s 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 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,Nancy ** F[redacted], Esquire UPMC- Health Plan — Legal

Re: Complaint No. [redacted] Dear Ms. [redacted]UPMC Health Plan, Inc, ('‘UPMCHP") has received and reviewed your letter dated December 12, 2016, as well as the accompanying complaint. Please accept the following as UPMCHP’s response to the complaint. The member complains that her health plan coverage...

was terminated without timely notice. The member states that she only learned that her coverage had been terminated effective December 1, 2016 when the pharmacy advised her on December 9, 2016 that she did not have coverage. She seeks reinstatement of her federally facilitated (FFM) UPMC EPO Silver plan.Investigation of the member’s complaint reveals a pattern of unpaid balances dating back to September 2016. In October 2016, the member was sent a letter advising of an unpaid balance with notice that her coverage would be terminated if the past due balance was not paid. The member also had an unpaid balance as of November 2016, and received a reminder call on November 15, 2016 that unpaid premiums were due by December 1, 2016. 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 will be able to reinstate the member if she satisfies in full any balance on her account that remains past due. UPMCHP has outreached directly to the member to communicate this proposed resolution.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 Stacey *. J[redacted] Esq. at ###-###-####.Sincerely,UPMC HEALTH PLAN Legal Services Department

#[redacted].To: Revdex.com <[email protected]>Complaint has been fully resolved.Thank you

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted].
I find that their response which was sent to me directly has addressed many of my concerns.  Regardless of whether I find their responses satisfactory or not, it is appreciated. I am not entirely satisfied that UPMCHP will effect any real change that will avoid for other customers the issues that led to my complaint.  I will present any further concerns directly to the company as they have asked that I forward marketing material that I found questionable to them. The wording of said marketing material was part of my previous complaint. A copy of the marketing piece has been attached and may be forwarded to UPMCHP. After which,  the Revdex.com may close this complaint. 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.
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]

Review: In the beginning of October 2015, my husband was complaining of abdominal pain. We went to [redacted] where the doctor advised us he thought my husband had appendicitis and we needed to go to [redacted] Hospital ER because it was the closest emergency room. This was a Sunday afternoon, so when I called UPMC’s customer support number, there was no one in to give us advice about being seen at an out-of-network facility. Assuming that the doctors at [redacted] Hospital would alert us if there was an issue taking UPMC insurance, we went there. After running a few tests, the nurse said that they had already phoned the surgeon, that they would need to admit my husband and do surgery to remove his appendix. Everything went well.

The next morning, I called UPMC again and was advised that as long as we were admitted through the emergency room, we would be considered in-network, we just needed to have a waiver put into my husband’s file. When I inquired about this form to the nurses, we were told that would have no bearing on billing – that we were going to be out-of-network. Our social worker at the hospital got on the phone with UPMC and proceeded to have a conversation about said form, to which I thought it was agreed that we would be in-network.

A couple weeks later, we got an out-of-network bill. We filed an appeal based on the fact that he was considered 23-hour observation and that he was never officially admitted to the hospital. The appeal was denied in December. I immediately called UPMC back and the woman I spoke with said it wasn’t an admittance issue – [redacted] Hospital coded as ambulatory care instead of emergent. While I was on the phone, this woman made a call to [redacted]’s billing dept and left a message about changing the codes. She advised we wait and see what the hospital comes back with. We waited until the beginning of April, when I got a bill saying our account was severely delinquent. When I called the hospital, they said they have no record of that message. UPMC says there’s nothing further I can do to fight the appeal because it has been longer than 60 days from the first appeal.

My complaint is about the absurdity of how this is being handled. Because his care was coded as ambulatory aka outpatient - even though he was admitted to a hospital room THROUGH THE ER and his discharge paperwork says he was admitted – we are going to have to pay an additional $5000. I am not denying that we owe money and am fully vested in paying the in-network deductible. But, when a doctor says you need emergency surgery, what non-medical person is going to question what hospital you need to go to, or to ask for a transfer (I’ve only found out about this through this situation)? My husband was admitted to surgery through the emergency room, so why should the aftercare (outpatient) be the determining factor in how we are billed.Desired Settlement: I want our bill to reflect our in-network deductible.

Business

Response:

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 AttorneyUPMC Health Plan

I received a letter in the mail in January from UPMC offering me a $25 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.

Review: We have an overpayment of $63.44 sitting on the account used to pay for the health insurance for my husband's daughter since January 2015. We have contacted UPMC five times and have been told we would receive a refund for this overpayment, however, we have not received our refund to date, though we do keep receiving statements showing the credit monthly. March 16th, I spoke with both Joy and Janelle at UPMC and was told the refund request was put through again. When never received, I called again on 5/12/15 and spoke with Annette, who told me she would investigate the refund and call me right back. I have not received a call back from UPMC to date, nor have we received a refund. We did receive another statement this week showing the refund is still sitting on the account.Desired Settlement: We would like to receive our overpayment on this account. We obtained healthcare for our daughter elsewhere in January and no longer require services from UPMC. The account information is as follows: Member ID # [redacted].

Thank you kindly for your assistance in resolving this matter.

Business

Response:

Re: Complaint ID: [redacted]Dear Ms. [redacted]:UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated May 21, 2015, as well as the accompanying complaint filed at the above-captioned file number. In accordance with the directions included in your leuer, this response will not personally identify the member.As we discussed on the telephone, the above-referenced letter did not include a HIPAA Authorization to disclosc protected health information. Without a HIPAA compliant authorization, UPMCHP is unable to provide a response to the Better Business Buieau to this complaint. However, per our discussion, UPMCHP will outreach to the complainant directly.Thank you for bringing this matter to our attention. Should you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely[redacted] Esq, UPMC Health Plan