(Transcribed from the original, received November 9, 1998)
Always First In Health Plans
World Houston Plaza
15710 JFK Boulevard, Suite 500
Houston, TX 77032
(281) 986-8000November 5, 1998
Mr. R. James Martin
501 Sycamore Lane, #327
Euless, TX 76039
Dear Mr. Martin:
Enclosed you will find a spreadsheet which was prepared by First Health in response to your appeal letter of September 13, 1998. The spreadsheet contains a listing of previously denied claims submitted in your behalf by Dr. Xxxxxx beginning January 24, 1996, and continuing through December 18, 1997. The spreadsheet reflects the results of First Health's review of your appeal and it provides you with the reasons each claim was originally denied as well as claims that have been subsequently adjusted.
To assist you in understanding the spreadsheet, in particular the reasons for the denials, I am providing you with an additional explanation for some of the entries. For example, if a claim has been denied for duplicate charges, that means that the provider submitted the same claim twice. Some claims were denied as not being medically necessary as that definition is found in the MRG Plan document (see, plan document at pp. 51-52).
A denial described as "global" means that a procedure performed by the provider was broken down into separate charges when only one charge should have been submitted. For example, a charge for an injection usually includes the cost of administering that injection. Providers may, from time to time, break down the injection and submit separate charges for each component of the procedure, and this is typically disallowed.
In a few cases, charges were disallowed because the treating physician did not submit the documentation necessary to establish medical necessity.
All denied charges have been reviewed by a First Health physician consultant. Following that review, the physician instructed First Health's claims department to adjust some denied claims and pay them. Those claims are reflected on the spreadsheet. In addition, Explanation of Benefit forms identifying those claims which were previously denied but have been adjusted are being sent to you and payment, if any, will be sent to the provider.
As previously explained to you, your September 13, 1998 letter has been treated as your second appeal under the MRG Plan document. The Plan document provides for a two step appeal process (see you Benefits booklet on pp. 27-28 or the Plan document at page 85). Therefore, you have exhausted your appeal rights under the Plan. Any subsequent requests regarding specific claims which have already been addressed in you appeals must be directed to the MRG Plan. First Health cannot accept a third or subsequent appeal without express directive from the Plan.
Please feel free to contact me if you have any further questions.
Very truly yours,
(mary jo thompson)
Mary Jo Thompson
Manager, Support Services
Enclosure: Spreadsheet
