(Transcribed from copy received October 16, 1999) (TDI stamp indicates they received October 12, 1999)
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Always First In Health Plans 3200 Highland Avenue |
October 7, 1999
Texas Department of Insurance
LA& H Intake Unit
Complaints Resolution 111-1A
Consumer Protection
P.O. Box 149091
Austin, Texas 78714-9091
Re:Document I.D. No. 424921
Participant – Ronald James Martin
Dear Intake Unit:
I am writing on behalf of First Health Group Corp. ("First Health") in response to the above-referenced complaint filed by Mr. Ronald James Martin. As an initial matter, Mr. Martin’s benefit plan is a qualified self-funded ERISA plan. Notwithstanding that the Texas Department of Insurance does not regulate such plans, we will offfer you information in response to your inquiry (without waiving the position that this plan is not subject to your department’s jurisdiction).
As background, I would like to explain First Health’s role in this case. First Health is not Mr. Martin’s insurance carrier. In this instance, First Health was performing third party claims administration services relating to the treatment of Mr. Martin. First Health performs claims administration on behalf of its client (Mr. Martin’s benefit plan provider) Metromedia Restaurant Group. As a third party administrator, First Health is required to process claims according to the terms and conditions of the Metromedia’s health benefit plan (the "Plan").
First Health and Metromedia have been working for some time to address Mr. Martin’s concerns regarding payment
of his medical claims. We believe that First Health (and the Plan) have acted in accordance with the terms
of ERISA and the Plan in responding to Mr. Martin’s appeals. To demonstrate this, I will attach copies of the pertinent
coorespondence which has been exhanged. On September 13, 1998, Mr. Martin wrote to First Health raising
a number of issues relating to claims which First Health had denied over an extended period of treatment.
(See attached.) First Health treated this letter as an appeal of claimns which
had been denied, and in response, First Health sent Mr. Martin two letters dated November 5, 1998. (See
attached. first - second) The first
of these was sent by the claims office, and included a spreadsheet which listed each of the claims which had been
considered on appeal. For those claims which First Health determined that adjustment was required, the information
concerning the adjustment was listed. For those claims for which First Health upheld the original denial of the
claim, First Health included the basis for that denial. The second First Health
letter dated November 5 addressed some of the other concerns Mr. Martin had raised.
Mr. Martin wrote a letter in response to the November 5 letters which was dated November 21, 1998, and which he directed to Metromedia. (See attached) On December 28. 1998, Metromedia wrote to Mr. Martin informing him that it would treat the November 21 letter as the second level of appeal provided for in the Plan. (See attached). In conjunction with this second level of appeal, we understand that Metromedia submitted Mr. Martin’s medical claims and records to an independent physician. The results of this review (and Mr. Martin’s second appeal) were communicated to him in a letter dated April 23, 1999. (See attached.) The result of the appeal was that most of the original denials were upheld. There were, however, certain claims which the Plan determined should be paid, and Metromedia directed First Health to pay those claims. On May 6, 1999, First Health sent Mr. Martin an updated spreadsheet which reflected the adjustments that the Plan had directed First Health to make. (See attached.)
Mr Martin makes allegations in his letter to the Department of Insurance that First Health has not made the adjustments which were to have been made pursuant to the outcome of the second appeal. First Health believes in fact those adjustments have been made. If there are specific claims which Mr. Martin can identify as those he believes have not been adjusted, we can investigate further.
I hope this information has been helpful to you. Should you have any further questions, please call me at (630)241-7415.
Very truly yours,
(illegible scrawl)
Margaret B. Jones, Esq.
Director and Associate Counsel
Enclosures
