UPMC Health Plan

Review: In November of 2014, UPMC offered a free $10 CVS gift card for those non members that requested information on their 2015 Medicare Advantage programs.Both my wife and I applied for this information and each requested a gift card.Those cards were received on January 6th, 2015.We tried to use them on January 14th at the CVS store in Latrobe, PA to purchase some L'Oreal face cream.The cards were rejected and according to the CVS store associates were not valid for face cream only prescription or other health related items.We subsequently called both CVS and UPMC customer service to understand this and explain this is not what the promotion by UPMC indicated....there were no restrictions other than for alcohol or tobacco on the original offer.The flyer that CVS put out has that skin care would be one of the items that these select gift cards could be used for.This seems like a fraudulent promotion by either CVS or UPMC.We have spent an unusual amount of time on the phone with a number of customer service representative to help clarify our situation all to no avail.For such big companies like UPMC and CVS this is extremely poor service onsuch an item like at $10 gift card.Desired Settlement: Provide us with 2 gift cards for $10 each that does not have the restrictions for face cream as we tried to purchase and can be used on general CVS merchandise.

Business

Response:

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

Review: On 6/26/2014 I was seen for a Surgery Consultation with Dr. [redacted] for a surgery consult. Before this consultation took place, I was assured that my UPMC health plan would cover it. Approximately two weeks later I received a bill for $40.00, my copay, and in the bill it stated Insurance pending. Two weeks after that on 7/25/14 I got an EOB from UPMC saying it would not cover the claim. I immediately called UPMC Health Plan and asked why. They told me that the doctor's office had put in the wrong diagnosis code, and to wait two weeks so that they can get it straightened out. This was at the beginning of August. On approximately August 14th. I received another bill for 406.00, the full amount that he charges. In the meantime I never heard back from UPMC. I called Dr. [redacted]'s secretary within a few days, and she told me that the office had put in the wrong diagnosis code and they will resubmit it to UPMC. she also told me that her office heard nothing from UPMC before I called. Another two weeks go by, and I still never heard anything from UPMC. I called UPMC at the beginning of September, to see what was going on. They told me that they will have University of Pittsburgh of Physicians, the place where I got the bill from, and have them try to straighten it out. I never heard anything for at least another 2-3 weeks until a got another bill from Dr. [redacted] charging me the full amount, and saying it was past due. I am tired of UPMC playing games, lying to me, and making no attempt to rectify this situation for nearly two months now!!My next step is going to get in contact with the PA Attorney General regrding this matter.Desired Settlement: UPMC needs to actually do what they are getting paid for, get the right diagnosis code and pay the bill their responsible for already!!!

Business

Response:

UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your complaint filed with the Revdex.com on September 23, 2014 (Complaint ID: [redacted]). The Revdex.com indicates that you were provided with a HIPAA compliant authorization to disclose protected health information, but that you did not complete and return the authorization to it. As such, the Revdex.com has directed UPMCHP to reach out to you directly regarding your complaint.

Your Revdex.com complaint is in regard to an Explanation of Benefits from UPMCHP and subsequent bill from your provider, Dr. [redacted], in the amount of $406.00. The claim in dispute was initially denied because the primary diagnosis listed by your provider was not a covered diagnosis. UPMCHP has received three additional primary diagnoses for this claim and for which you received treatment, all of which are valid and payable diagnoses. Accordingly, this claim will be reprocessed and paid in accordance with your benefit plan, subject to any applicable copayments or coinsurance.

Our records also indicate that you did not file any complaints or grievances with UPMCHP related to this matter. Your Certificate of Coverage outlines the processes for resolving disputes with UPMCHP. Following these processes may result in a more expeditious resolution of any concerns or issues you may have. A copy of your Certificate of Coverage is available online. If you need additional assistance regarding your Certificate of Coverage, please call the Member Service Department at ###-###-####.

UPMC Health Plan considers your input a valuable source of information, and we believe member communication helps us improve our services. If you have any other questions, please call the Member Service Department at ###-###-####.

Thank you for alerting us to your concern.

Sincerely,

UPMC Health Plan

Review: UPMC Health Plan has recently refused a prescription that I have been getting for several years now, under UPMC Health Plan. I had a prescription filled on 09/17/2013 for 90mg of a certain medication. When I tried to refill the same prescription on 1/13/2014, they refused because of the dosage, even though, UPMC has paid for this same prescription at the same dosage several times in the past. I called UPMC and have explained the situation. They told me to contact my prescribing Doctor. I have tried getting in touch, and left several messages for him to no avail. I have explained this to UPMC and they told me there was NOTHING they could do. The next step will be to contact the Attorney General's office about this matter.Desired Settlement: UPMC needs to follow up on their refills, and not leave the patient hanging for days without the prescription. UPMC neeeds to approve this refill, esescialy since I did all I could to try to remedy the situation myself. This has been going on for 10 days now, and if something is not done soon, I will have no choice but to take this matter further.

Business

Response:

Review: We have a grandfather clause with our health insurance -- we began this coverage on July 1. Prescriptions that normally require pre-authorization were to be grandfathered in if they were refilled during the first 45 days of the plan. I was told that after the 45 days 2 of my husbands medications and one of mine would need pre-authorization. Based on this wrong information, I spent hours on the phone with UPMC, our doctors filled out unnecessary paperwork and my health conditions have been aggravated. I now have learned from my employer that UPMC was wrong and none of this was necessary!!!!Desired Settlement: I at least want an apology, and more importantly, others should not have this kind of experience. Insurance companies need to be held accountable for their actions.

Business

Response:

UPMC Health Plan

August 6, 2013

Re: Complaint No. [redacted]

Dear Ms. [redacted]:

UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter of July 24, 2013, as well as the accompanying complaint submitted by a consumer of UPMCHP's group insurance product (the "Consumer") at the above-captioned file number.

Consumer is an employee of [redacted] ("[redacted]"), a self-funded employer group that enrolled with UPMCHP effective as of July 1, 2013. As part of [redacted]’s transition to UPMCHP from its previous insurance carrier, the parties negotiated a 45-day "transition period’' with respect to prescription drug coverage. Specifically, UPMCHP agreed to waive all prior authorization and step therapy requirements on medications for the period from July 1, 2013 through August 14, 2013. It is important to note that, at the specific direction of [redacted], the 45-day transition period initially did not apply to quantity limits.

On July 8, 2013, Consumer attempted to fill two prescriptions - one for [redacted] ([redacted] mg) for a quantity of 180 capsules for 90 days, and a second for [redacted] (** mg) for a quantity of 180 capsules for 90 days. The prescription for [redacted] paid with no issues, but the prescription for [redacted] rejected due to a quantity level limit (per UPMCHP formulary guidelines, [redacted] fills are limited to 90 capsules for a 90-day period). Compounding the confusion, the rejection was initially overridden by UPMCHP due to a miscommunication within UPMCHP’s pharmacy department regarding the nature and extent of the transition period waivers. However, as a result of this miscommunication, Consumer received a benefit in that she was able to fill the [redacted] prescription in an amount in excess of the established quantity limit.

On July 11, 2013, the Consumer contacted UPMCHP’s Member Services Department, and was advised that while prior authorization and step therapy requirements were waived during the 45-day transition period, quantity limits would still apply. On July 17, 2013, representatives from [redacted] notified UPMC Health Plan that they had decided to include a waiver of quantity limits in the 45-day transition. Subsequently, on July 18, 2013, the Consumer’s physician submitted a request for coverage of [redacted] at the increased quantity of two capsules per day. On July 19. 2013, that request was reviewed and approved for a period of one year. As such, despite the initial communications (and subsequent reversal of course by the employer) regarding the applicability of quantity limits during the transition period, the Consumer ultimately received the prescription drug benefits sought.

In her complaint, the Consumer expresses concern about the level of service that she received during multiple calls to UPMCHP's Member Services Department. 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 confusion that may have been created during

the Consumer's various calls to member services representatives. The 45-day transition period was a customer accommodation made specifically for [redacted], and is outside of UPMCHP’s normal ‘‘new group" onboarding process. As a result, there may have been a certain degree of confusion regarding the applicability of prescription quantity limits. The Consumer’s concerns have been referred to the manager of Member Services and her comments will be used to prevent similar problems from occurring in the future. As the Consumer has received her requested relief at this point, we consider this matter to be resol ved.

Review: This happened awhile ago and I wish I had thought to file this then. But I was,and am, having issues that I believe are related to my having had my [redacted]. I also want more children. I had my [redacted] because I was pressured by doctors because I had high risk pregnancies and a back issue. But I think it was the wrong choice. I researched online and saw that it is very rare that a reversal is covered by insurance. But to calls and ask and if they say it is get it on record as a recording. So I called and they said it was 100% covered after deductible! They said they don't allow recording but could give me a number that would allow the phone call to pulled up. I hung up and called again and for the same anwser! So I then proceeded to have testing done, my husband took off work to have testing done. This entailed multiple appointments at an hour drive, parking fees, has money, time off work for my husband, babysitting, and copays. The testing was done, the surgery scheduled, my mom had taken off work to help me with my kids after the surgery. I was so excited. The surgeon, the anasteologist, everyone had called in and been told they it was covered. Then I lost the sheet with the number on it from the recorded call and I called in to get a new one so I would have documentation in case something came up after the surgery. They said it wasn't covered. I was in tears and hung up and called again and same thing. I called the office of the dr performing the surgery and the ran something (why they didn't in the first place I don't know) and it came back denied. They said pay 10,000 or cancel the surgery. So I had to cancel the surgery. They said I was lucky I would have been responsible for the 10,000 after the surgery. I didn't feel lucky. I appealed and appealed to no avail. It was something in my husbands policy that caused the denial. In the end they admitted that their reps need more training. But they wouldn't honor what I was told and allow me to have the surgery and worse yet they still made me pay for all of the doctors visits toward my deductible and the copays. All based on misinformation. ITs their job to tell you what is covered, that's why you call in. If what they tell you is allowed to be wrong with no guarantee then what is the point? I might as well guess myself and hope for the best.Desired Settlement: I would like to be able to have the surgery. I was told that I could. Barring that I would like refunded for the money paid toward my deductible, the copays, and all the out of pocket expenses

Business

Response:

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 number. In 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 plan. Between July and September of 2013, the member contacted UPMCHP on several occasions to inquire as to whether a [redacted] reversal was covered under her plan. Initially, the member received incorrect information from a Member Services representative and was told that the procedure was a covered benefit. Prior 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 benefits. UPMCHP 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 involved. However, 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, 2013 and August 22, 2013. UPMCHP has reviewed the dates of service in question and has confirmed that the member was billed correctly in accordance with her coverage. On August 2, the member incurred a $40 copay for visiting a specialist, which is the standard copayment amount under her plan. She was also charged $98.45, which applied to her deductible, for services received on August 22, 2013. 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 attention. Should you have any further questions or concerns, please do not hesitate to contact me at ###-###-####.Sincerely. [redacted] Esq.

Review: In 2014 I was getting [advertisement] mail at my home for two people that don't live at my address nor have ever lived at my address. On September 10 2014 and September 13 2014 I sent UPMC for Life letters requesting they stop sending me mail for these two people that have never lived at my address. The mailings stopped but now today August 28 2015 I started getting mail again from UPMC for life under one of the names. It came under the name[redacted] 15202 [redacted]And just in case it ended up back on their mailing list the other name was:[redacted]UPMC needs to stop sending mail for [redacted] to my address and if [redacted] is on their list again do not send anything under [redacted] Sr to my home.Desired Settlement: Stop sending me mail for [redacted] and do not send anything either for [redacted] if [redacted] ended up on your mailing list again.

Business

Response:

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

Consumer

Response:

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]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] at my address [above]. No such people have ever lived at my house.Sincerely, [redacted]

Review: upmc owes me a refund of 1yr preempitive health care for a membership at a local ymca---sent the hospital form in september 2013 and they have 45 days to reimberse a patient--they lost the first papers I sent by mail--and a few weeks went by and they had me fax them the same information-so the date I sent that was 11/3/13-its past 45 days on that also and I still dont have my check-after many many calls to them over the last mo or so I have got lied to many times amd put on hold sometimes for 20 or 30 minutes-all I want is my check and this letter to go on record somewhere so they cant do this kind of thing to anyone else-thank youDesired Settlement: my check that they owe me sent right now

Review: My husband and I are subscribers through my husbands employer to the UPMC Health Plan. I was prescribed by my midwife for my pregnancy to go to a diabetes educator at Magee Womens Hospital to be tested for gestational diabetes for my pregnancy. We have tried to discuss their errors with them however they keep stating that it is "coded differently". I don't care how it is coded, my health plan clearly states that it is covered. It does not state it is covered, unless something is done that we don't approve of. We have filed a complaint through UPMC, but of course when you complain to the source they still want their money.Desired Settlement: The billing for the visit will need to be adjusted to zero dollars. I will not be paying for a service, that my insurance already states is covered. We will continue to fight this illegal attempt at collection until the rectify the issue.

Business

Response:

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

Review: [redacted]I have been prescribed a medication to control symptoms of [redacted] for over three years, and I recently switched my health insurance plan to UPMC For You. After having switched to my new plan, I was told I would need a prior authorization (p.a.) to fill my prescription, but because I need to take the medication daily, I had to pay for the cost of the medication up front and then seek reimbursement after the p.a. had cleared. The p.a. was denied, however, because I had not yet met UPMC's own criteria for being diagnosed with [redacted] in order to meet that criteria, I would have to make an appointment with my primary care physician to take a test. The test, it turns out, is designed for parents of children who may have the disorder, with most of the questions were stated in the form "Does your child..." (I am 30 years old). After I passed this screening, my p.a. was approved, and I was able to fill my prescription. Upon seeking reimbursement for my original purchase through UPMC's "Fast Scripts" program, however, I received a letter stating that because I had not met UPMC's criteria for diagnosis before making my purchase, they would not reimburse me for my prescription. So, after all was said and done, even though I was insured by UPMC at the time of my out-of-pocket purchase, took the time off to make a doctor's appointment to pass their screening that was designed for children, and got the p.a. that was required to fill my prescription, my insurance company would not allow back-payment for the medication that I am required to take daily. I was told on the phone, after hours of waiting on hold between conversations with customer service reps, that they would not back-pay previous to the time that I "met the criteria," which was the screen test- Before I was eligible to be reimbursed, they had to know first if I am "difficult to control at the mall or department stores," if I "have trouble sitting still for long periods of time" and if I "get angry or irritated easily." I would not be the least bit surprised to learn that UPMC has similar "criteria" that they use to get out of paying for the first month of prescriptions for a host of illnesses.Desired Settlement: Immediate reimbursement of the amount I paid out-of-pocket for my prescription while I was insured by UPMC. Reference number is [redacted].

Business

Response:

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

Review: UPMC has been extreemly slow in paying for my claims. I have received notices from my Dr's that my insurance company has denied my claim. I end up having to call in and find out why and I usually get "we will look into it and get back to you" NO ONE CALLS YOU BACK! I have called so many times regarding my claims that I am on a "re-peat caller" list. I was directed to only speak to a manager and was given her direct line. They were going to review and re-submit all of my outstanding claims and get back to me.....never heard back from her. So I went to our outside insurance representative, sent her all of my bills and still do not have the issue resolved.I have started receiving letters from collections agency's because my bills have not been paid. In 1 week's time, I received 3 different statements and phone calls regarding 1 bill with 3 different amounts. Come to find out, I over paid and I received a check in the mail from the Dr's office.My annual deductible is $1,250. I have bills going to in-network Hospitals for 1 date of service for $5,720. This visit took place in November 2012. I met my out of pocket amount in January 2012.If I had a choice, I would not have UPMC for my insurance but my employeer has selected them so I have no choice but to deal with itDesired Settlement: UPMC needs to be held accountable for their actions. If they say that they are going to find out about an insurance claim, then they need to follow up and let their customer know what they are responsible for paying. We have to pay for the insurance, we have to pay for our bills. If we do not, we get sent to collections. That is where I am at right now. I have worked hard to have a decent credit score and now due to medical bills, it is going right down the toilet!

Business

Response:

UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated July 29, 2013, as well as the accompanying complaint submitted by [redacted], a consumer in 2012 of a UPMCHP PPO fully-insured plan ("Consumer’).

?????In her complaint, Ms. [redacted] complained that UPMC Health Plan failed to pay a hospital claim in November 2012 correctly. She also slated that the no one from Member Services ever returned her calls about this issue.

Multiple claims were received from [redacted] and [redacted] for date of service on November 30, 2012. The claims were received by the Health Plan on December 7, 2012, and processed timely. Out-of-network providers, such as [redacted] and [redacted], are covered at the Reasonable and Customary Rate, which is the rate that UPMC Health Plan determines is reasonable for Covered Services.

As a result of the Consumer's most resent calls to Member Services stating she was being balance billed, the claims were re-reviewed and it. was determined that the [redacted]) rate should have been paid to this provider; therefore, additional payment was due. On August 7, 2013, the claims were reprocessed and paid in full. The Consumer is not responsible for the charges.

Regarding the Consumer's concerns about Member Services, it appears that the member has had to call multiple limes on this issue and the calls were escalated to a supervisor level. While we cannot determine were the breakdown occurred, the Consumer's concerns will be reported to the appropriate manager of that department for further review.

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 breakdown that may have been occurred during the Consumer’s various calls to Member Services representatives. As the Consumer has received her requested relief at this point, we consider this matter to be resolved.

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

Review: I signed up with UPMC Health plan for my family because I needed 2 months of coverage until my wife's insurance started on 11/1/2015. My coverage with them started in September. Around the 3rd week of October, I called them to have my insurance cancelled on Oct. 31st. They told me to write a letter and fax it to 412-454-7770, which I did. I called a week later to check that they got it, they said they didn't. I told that person I needed the policy cancelled, so they "made an exception" and cancelled it. In the meantime, they auto charged me for my November policy...I did NOT sign up for autopay, because I knew it would only be for 2 months. I called back to request a refund...they told me the last rep I spoke to didn't cancel my policy!!! I told them again I needed it to be cancelled, and that I wanted my refund. They told me it would be 4-6 weeks for the refund, which I told them was unacceptable since A. it wasn't cancelled 3 times like it should have, and B. that I never authorized autopay. They said to call back in 7-10 days. I did, and that rep requested I get the credit back in 5-7 days. When I didn't get the credit, I called back and asked to speak to Donna the supervisor. The girl said she was busy, and I asked for her to leave a message for Donna to call me. The girl replied "well she is busy, so I don't know if she can return your call". Really! So, almost a week has gone by, no call from Donna, and no refund. I am owed a refund of $649.19.Desired Settlement: An immediate refund to my credit card, which they were not authorized to auto charge to begin with.

Business

Response:

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

Review: UPMC for Life offered a free CVS Pharmacy Card for non member that are looking for information on their Medicare Advantage options. I called in on 11/12/2014 and requested information along with providing a reference number for this promotion for both myself and my wife. The numbers are 00-77LQ2537761 for myself and 00-77LQ2117402 for my wife Judith.So far after 2 months, we haven't received the cards as promised.Desired Settlement: Provide the CVS cards as promised at a value of $10 each.

Review: In the beginning of August 2015, I took my wife off of my health insurance, as she was getting coverage through her employer. UPMC continued to bill me for her, through direct payment from my checking account, for the months of September and October. I then cancelled my policy all together, as I picked up coverage through my employer. After 4 months and numerous phone calls, they have still not reimbursed me for the two months I was charged for my wife. They fully acknowledge her coverage was cancelled, explain that I am due a refund, but I never get it. I also keep getting promises of phone calls to keep me informed of where my refund is, I only have contact when I call myselfDesired Settlement: I require a refund for the two months of coverage I was billed and paid for even though the policy was cancelled

Business

Response:

Re: Complaint No. [redacted] by [redacted]Dear Ms. [redacted]:UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated November 11, 2015, as well as the accompanying complaint submitted by [redacted].As we discussed in a telephone call November 16, 2015, 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,[redacted], Esquire Associate Counsel

Review: UPMC Health Plan is refusing to pay an emergency room visit claim. They were supposed to pay $2900 in July '12 and only paid $1385. I was sent to collections in December '12 for $1492, called UPMC to resolve issue. Assured me it would be handled. I thought it had been. I am now trying to buy a house and found that it is STILL on my credit, prohibiting me from obtaining a conventional loan. The one bureau that it is not on is over 100 points higher, putting me in Tier 1 credit, but the other two (that claim is on) is poor credit. I have called numerous times since August 5th, when I first discovered the issue, and everyone assured me that it would be taken care of in 10-15 business days. Two weeks ago I spoke with 3 separate UPMC Care Concierge (ha) persons who all told me that it had been approved and would be paid any day. Today a supervisor told me that they would not pay it, that the other reps had lied. This is negatively affecting my life and ability to purchase a house. I work hard, pay my bills, pay my insurance. This is a gross injustice!!Desired Settlement: I need them to pay the entire $1492 balance on the account and remove item from my credit immediately so I can move on with my life.

Business

Response:

RE: Complaint ID [redacted]

Dear Ms. [redacted],

UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated September 6, 2013, as well as the accompanying complaint submitted by a consumer of a UPMCHP insurance product (the "Consumer") at the above-captioned file number.

Consumer is a member of a Preferred Provider Organization ("PPO") fully insured plan. Under this particular plan, emergency services are covered at 100% after a $50.00 copayment. Out-of-network providers are covered at the Reasonable and Customary Rate, which is the rate that UPMCHP determines is reasonable for Covered Services.

Consumer visited the [redacted] on July 24, 2012. Under Consumer’s plan, [redacted] is an out-of-network provider and when UPMCHP originally received the claim on August 2, 2012, it was processed as such. This resulted in the claim being paid at the Reasonable and Customary Rate.

UPMCHP was not aware that Consumer was being balance billed for the remaining amount until Consumer contacted UPMCHP on August 5, 2013. At that time, UPMCHP contacted the provider and paid the claim in full, minus the applicable $50.00 copayment. UPMCHP also requested that the provider remove Consumer from collections and the provider agreed to do the same. Because only the provider can take this action, it is recommended that Consumer follow up directly with the provider to ensure that this has been done.

We apologize for any inconvenience this matter has caused Consumer and thank you for bringing it to our attention. If you have further questions or require additional information, please do not hesitate to contact me at ###-###-####.

Sincerely,

Staff Attorney

Review: I recently received a mailing at my home address. The mailing was an advertising come on for a Medicare booklet sponsored by UPMC for life. The mailing was addressed to my deceased mother at my address. It was not addressed to me; I'm not of Medicare age.I feel that the use of some type of data mining service of Medicare age eligible beneficiaries to send this blind advertising is awful. I consider this very intrusive and despicable.I verbally told UPMC for life of the situation; they stated they would remove my mother's name from any future mailings. However, it has still made me angry that any company can employ data mining to gather potential individuals to solicit for Medicare coverage, even if the individuals are deceased, not currently living at the stated address, and originally were not even in the catchment area for UPMC for life.Desired Settlement: Prompt removal of my mother's name in my address from the afformentioned database. I would also like the higher-ups at UPMC to investigate what sources they use for data mining to generate these advertising lists and mailers. It is reprehensible.

Business

Response:

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 ###-###-####.