(Transcribed from the original)
Always First In Health Plans
World Houston Plaza
15710 JFK Boulevard, Suite 500
Houston, TX 77032
(281) 986-8000
August 31, 1998
Ronald Martin
501 Sycamore Lane
Apt 327
Euless, TX 76039
Employee
Soc. Sec. No.
Employer
Dear Mr. Martin
Your e-mail of August 5, 1998 to Linda Farina has been referred to First Health for review.
Your coverage through Metromedia Resaurant Corp. was effective 03/13/95. At that time, the pre-existing condition stated "A pre-existing condition is any illness for which diagnosis, consultation or treatment (including prescribed drugs or medicines) has been received any time prior to the effective date of coverage." First Health began its pre-existing investigation in accordance with the plan guidelines at the time the initial claims were received. The final responses were received in June 1998 by which we were able to determine that no pre-existing conditions existed.
The Metromedia Restaurant Corp. Plan Document provides coverage for "Services or supplies which the plan administrator determines, in the exercise of its discretion, are generally acceptable by the national medical professional community as being sage and effective in treating a covered illness or injury , consistent with the symptoms ro diagnoses, furnished at the most appropriate medical level and not primarily for the convenience of the patient, a health care provider or anyone else." The medical records submitted by Dr. Mooed were reviewed by a clinical physician and nursing staff and the medical necessity for all services provided could not be determined. We have subsequently requested additoinal information from Dr. Mooed and upon reciept, the records will be reviewed again.
In your e-mail, you have also requested information regarding covered CPA and ID-9 codes and descriptions. There are too many variations in treatment plans to comply with this request.
Finally, you requested information regarding Plan information and the Appeals Process. This information, while not specific to your condition, is provided to you in the Metromedia Restaurant Group Plan Booklet.
Should you have additional questions, please contact our Customer Service Department at 1-800-833-5914.
Sincerely,
First Health
Appeals Department
JC
CC:
