|
Linda Farina |
October 11, 1999 |
Ms. Farina:
Following the receipt of your April 23, 1999 letter concerning "…our response to your second and final appeal.", (where a number of claim denials were upheld, and a number of claim denials were overturned), I was under the distinct impression that we had resolved what the law and The Plan required when an adverse action for a claim takes place.
"shall provide to every claimant who is denied a claim for benefits written notice setting forth in a manner calculated to be understood by the claimant:
- The specific reason or reasons for the denial;
- Specific reference to pertinent plan provisions on which the denial is based;
- A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary and;
- Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review."
Imagine my consternation upon receiving EOBs for claim(s) 927816390024 and 927816390014, both having a denial reason code of "811: Professional review has denied payment for this procedure."
No such language exists in The Plan.
Along with First Health’s unconscionable and repeated requests for information they already have (the subject of my August 29, 1999 e-mail to you, and still unresolved), and this latest reversion to practices contrary to the law and language of The Plan, I’m really at my wits end. Can you get this resolved A.S.A.P.?
Thank you,
R. James Martin HER REPLY
I Waited A While, Then...
HER REPLY
The First Health Reply (favorable
for a change)
Date: Wed, 13 Oct 1999 17:14:59 -0500
From: LINDA FARINA <LFARINA@metrogroup.com>
To: rjamesmartin@yahoo.com
Subject: Denied Claims -Reply
I will ask our First Health account rep about the 2 claims you listed in this message. If you would like to have
Sherri or me look at other claims or correspondence that you are concerned about, please let us know specifically
which claims you are referring to.
>>> "R. James Martin" <rjamesmartin@yahoo.com>
12/03/99 04:07am >>>
Well, here it is December already, and the usual slow no response forthcoming is taking place.
Your fine assistance has resulted in zero claim payments for 1998 and 1999.
What would it take for you to undig your heels and get something positive done for the beneficiaries of the plan?
Date: Wed, 08 Dec 1999 14:44:29 -0600
From: LINDA FARINA <LFARINA@metrogroup.com>
To: rjamesmartin@yahoo.com
Subject: Re: Denied Claims -Reply -Reply
James, I was contacted today by First Health about your claims 927816390024 and 927816390014. They have prepared
a response and it is being mailed to you this afternoon.
(Transcribed From The Original)
December 8, 1999
R. James Martin
501 Sycamore, Apt. 327
Euless, TX 76039
Dear Mr. Martin,
I am writing in repsonse to your letter of October 11, 1999, to Linda Farina, Senior Director Employee Benefits
for Metromedia Restaurant Group. Because you were questioning the outcome of the claims determination, we treated
you letter as an appeal of claims 927816390024 and 927816390014. Ms. Farina forwarded your request for an appeal
to First Health. The claims designated in your letter,
as well as the cooresponding medical information were received, and sent to a First
Health Medical Director
(FHMD) to review the medical necessity of the services billed in these two claims, 927816390024 and 927816390014.
The FHMD reviewed the available medical information pertinent to these two claims and recommended certification
of all charges with the exception of the charge for transportation of laboratory specimens from your physician's
office to the laboratory. However, it is my understanding that your benefit plan has chosen to pay this expense
with respect to these two claims. Therefore, Ms. Farina has directed First
Health, in its role
as third party claims administrator to Metromedia Restaurant Group, to pay the claims within ghe context of the
benefit plan.
I trust this issue is resolved to your satisfaction. If you have any additional questions or concerns pertaining
to this issue, please direct them to your benefit plan.
Sincerely,
Margaret B. Jones, Esq.
