ComplaintsforBlue Cross Blue Shield of Alabama

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Initial Complaint
12/12/2023
Complaint Type:
Billing Issues
Status:
Resolved
The complainant verified the issue was resolved to their satisfaction.
On 8/25/23 I had a pre-approved Lung Scan performed at ***************************** (provider) using my Blue Cross of Alabama ***************** Contract No. BEG881073369. Shortly thereafter I received a Claim Notification No. ************ from Blue Cross stating that I owed the provider a total negotiated amount of $140.32. I had already hit my yearly Out of Pocket Maximum for the Insurance, so I called Blue Cross and explained that I should owe nothing. They agreed and "reprocessed" the Claim with a new Claim No. ************. This was in early September 2023. The provider has still not been paid. I have called Blue Cross multiple times and the new Claim No. has been in some kind of "hold/error" status for months. In the meantime, I had to pay the provider directly because they were threatening to send the bill to Collections and wreck my credit.I want Blue Cross to process the $140.32 claim and pay the Provider so I can then (hopefully) call the provider and get my original payment back.
Business response
12/22/2023
December 22, 2023

************
XXX
XXX

Name of Patient: ************
Contract Number: BEG888888888
Claim Number(s): ***********
Date(s) of Service: August 25, 2023

Dear ************:

We are responding to your complaint concerning your claim for date of service August 25, 2023.

We have researched your claims for 2023 and found that you have indeed met your out of pocket maximum for this year. The claim for date of service August 25, 2023, applied to your copay in error. After further review, we found a system's problem,which is causing it to process incorrectly. We are currently correcting that problem and will reprocess your claim.

We regret and apologize for this and are working diligently to get you claim reprocessed.

Sincerely,

Customer Service
Customer response
01/02/2024

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me....assuming the claim eventually gets reprocessed correctly

Sincerely,

*******************
Initial Complaint
12/05/2023
Complaint Type:
Billing Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
We filed for a refund after we had paid our provider. Blue Cross Blue Shield paid the provider, and the provider did not forward the money back to us. Blue Cross had no reason to pay the provider as we did not file for them to pay the provider we paid the provider and paid for them to reimburse us. They made a mess out of this, and still do not understand the situation. The provider still has our funds and has not returned them lacrosse Blue Shield should refund reimburse us what we are out and get the phones back from the provider on their own.
Business response
12/15/2023
December 15, 2023

*************
XXX
XXX

Name of Member: *************
Contract Number:       MBG*****9548

Dear *************:

We are responding to your rebuttal concerning payment for claim number 001-2050137 in the amount of $225.

We contacted the provider and requested a copy of their canceled check which they sent you a refund. Based on the copy we received, a check dated September 19, 2023,was issued to you in the amount of $190 under check number ****. A signature with your name is endorsed on the back and it shows it cleared the bank on September 22, 2023. Since you paid the provider $225, we have issued you a check in the amount of $35 to cover the difference. The check was cut today and should be mailed by Monday.

If you need a copy of the canceled check, please contact the provider. We hope this information is helpful.

Sincerely,
Customer Service
Customer response
12/18/2023

Complaint: 20962982

I am rejecting this response because:
Once again, Blue Cross does not understand the situation. Yes they do have a council check for $190 which they did send us. The problem is that Blue Cross sent us two refunds, one of them for 190 and one of them for 225. We only received the 190. We still have not received a 225. The biggest problem is is Blue Cross was never supposed to send these refunds to the providers because at that time the providers did not accept Blue Cross and we paid out-of-pocket, and when we filed our paperwork we filed for us to be refunded the money that we have paid so the problem is Blue Cross has messed us up and the provider still has our 225. This has not been resolved and it is really blue crosses problems. They missed it up.
Sincerely,

*******************
Business response
01/16/2024
January 16, 2024

************
XXX
XXX

Name of Patient: ************
Contract Number: MBG888888888
Claim Number(s):         *********** and ***********
Date(s) of Service:        April 6, 2023, and April 24, 2023

Dear ************:

We researched your contract and found two more visits to the nurse practitioner ************************* on April 6, 2023, and April 24, 2023, each submitted for $135. Due to the contract between *************************, NP and Blue Cross and Blue Shield of Alabama, we are required to pay the provider. A payment of $97.07 was paid on each claim.Therefore, a total payment of $194.14 was made to the provider on August 10, 2023. We have contacted the provider regarding your refund for the above referenced claims. Please be advised, we will contact you as soon as we here from the provider.

We hope this information is helpful.
Sincerely,

Customer Service
Customer response
01/18/2024

Complaint: 20962982

I am rejecting this response because: She got paid twice, I file for the reimbursement on the correct forms but BCBS paid the wrong person. I want to speak to a person at BCBS who can understand what has happened.

Sincerely,

*******************
Business response
01/25/2024
January 25, 2024

************
XXX
XXX

Name of Member: ************
Contract Number:       MBG*****9548

Dear ************:

We have researched your claims history and had several conversations with the providers office.

Based on our review, there were three visits to *************************, Nurse Practitioner. As stated previously, date of service August 8, 2022, and October 11, 2022, under claim number 001-2050137 was filed for $225. The provider refunded you $190 and Blue Cross Blue Shield of Alabama (BCBSAL) issued you a check for the remaining $35. The provider also advised us that they later issued you a refund for an additional $30 which was less than your $5 copay. We also located dates of service April 6, 2023, and April 24, 2023, each for $135 under claim numbers *********** and ***********. The provider sent us information showing that you paid $100 on each visit for a total of $200. The providers office issued you a refund in the amount of $190 on September 20, 2023, which is all except your $5 copay for each visit.

Based on this information, you have been refunded all monies except your copay and an additional $35 was issued to you by BCBSAL. ************************* is a participating provider with BCBSAL and under our contract agreement all reimbursement will be issued to the provider. You should only pay your copay upfront. We hope this addresses your concerns.

Sincerely,

Customer Service
Customer response
02/01/2024

Complaint: 20962982

I am rejecting this response because:
The amount of money paid is incorrect. I did not receive the amount of money indicated. That
We would like someone from Blue Cross to call us so that we can discuss this matter and explain it. No one seems to be able to understand the situation.

Sincerely,

*******************
Business response
02/14/2024
February 14, ****

************
XXX
XXX

Name of Member: ************
Contract Number:       MBG*****9548

Dear ************:

As requested, we called you every day and left messages for a callback from February 7, ****, to February 9, ****. We were able to speak with you on February 9, ****,where you advised that you had not received the providers refund of $190.00.On February 12, ****, we contacted the provider and advised that you stated that you never received the refund of $190.00 that they issued you for dates of service April 6, 2023, and April 24, 2023. At this time, we are waiting for the provider to call us back with the copay of the cancelled check. If we have not heard back from them by next week, we will contact them again.

Our customer service rep will keep you informed.

Sincerely,

Customer Service
Business response
02/15/2024
Hi *****,
We sent a response yesterday advising that we have been in communication with *******************. Did you not receive it?

Thank you,
*************************
Customer response
02/21/2024
Blue Cross understands that there is a problem in that we have not reimbursed. They are trying to get it straightened out. We have not heard back from them. We did talk to a lady from Blue Cross who understood the situation and now understands that we have not received our money. The practice claims that they sent us two checks for $190 but they only sent one check for $190. Obviously, there was some insurance mistakes made and the practice has chosen not to correct this and Blue Cross Has also dropped the ball. We would like to be contacted again by Blue Cross.
Initial Complaint
06/14/2023
Complaint Type:
Customer Service Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
I am receiving inconsistent information on authorizations and would like to be contacted by the business for further clarification.
Customer response
07/13/2023
I have not heard from them either. Thank you for the update (well I guess lack of ha!).
Business response
07/13/2023
June 13, 2023

****************
XXX
*******, ** 88888

Name of Member: ****************
Contract Number: Unknown
BBB Case Number: 20184961

Dear ****************:

We have been contacted by the Better Business Bureau regarding your complaint related to inconsistent information on authorizations.

At this time, we are unable to locate a contract for you based on your address. If you have a Blue Cross and Blue Shield of Alabama Identification card, please provide the contract number from that card.

Please let us know if we can be of assistance in the future.

Sincerely,

Customer Service
Initial Complaint
03/02/2023
Complaint Type:
Billing Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Paid 277 dollars for them to tell me I need to see a PCP so they can verify the necessity of my BMT check *** and that they will not cover anything until I do, had them for one month and in that time they covered nothing.
Business response
03/14/2023
March 14, 2023

****************
XXX
XXX

Name of Patient: ****************
Contract Number: BEG888888888
Compliant ID: 19505747

Dear *******************:
We are responding to your complaint concerning the processing of your claim for
February 1, 2023. We received this complaint on February 27, 2023, and responded on February 27, 2023, with the
attached response.
We hope this information is helpful

February 27, 2023

****************
XXX
XXX

Name of Patient:           ****************
Contract Number:         BEG888888888
Claim Number(s):         309-0398316
Date(s) of Service:        February 1, 2023

Dear ****************:

We are responding to your complaint concerning the processing of your claim for February 1, 2023.

Our records indicate that you chose the Select Gold Plan through the Marketplace exchange. Under this plan,in Alabama, members are required to designate a select provider and all care must be coordinated through this provider. Referrals are required when utilizing providers other than the designated select provider. If these guidelines are not met, then there is no coverage. This information is listed in your online benefit booklet on the first page under "Physician Benefits." Since a referral is not on file, claim number 309-0398316 denied correctly. However, we show that you also have coverage through Blue Cross and Blue Shield of *********, and they paid this claim in full.

Please let us know if we may be of further assistance.

Sincerely,

Customer Service
Initial Complaint
12/01/2022
Complaint Type:
Order Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
My visit to TOC for orthopedic services on 11/29/2021 was for knee/leg pain and the claim was submitted. I had short term health insurance with BCBS Alabama and they denied it saying it is a pre-existing case. I had knee issues more than ten years ago due to a sports related injury and the recent one is not. TOC Office tried submitting evidence to BCBS saying it is not a pre-existing case still BCBS denied it. This is totally wrong and outrageous.***************************
Business response
12/06/2022
December 6, 2022

******************
XXX
*******, ** 35758

Name of Patient: ******************
Contract Number: QGX888888888
Claim Number(s): ***********
Date(s) of Service: November 29, 2021

Dear ******************:
We show under the guidelines of your short term policy, there are many exclusions which are listed in the
online benefit booklet. A letter was sent to the provider on December 30, 2021, which asked the question
had the patient received any medical advice, diagnosis, care or treatment for this condition prior to the
effective date of October 1, 2021, for this policy. Based on the response from the provider, this claim
processed correctly with a denial for a pre-existing condition. Under the guidelines of the plan, preexisting conditions are excluded.
We hope this information is helpful.

Sincerely,
Customer Service
Customer response
12/06/2022

Complaint: 18486720

I am rejecting this response because the physician's office presented evidence to the contrary that this is pre-existing. Just making a statement from you that it is, is not acceptable.

Sincerely,

***************************
Initial Complaint
05/18/2022
Complaint Type:
Service or Repair Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
In early May 2021, my dentist's office requested verification to cover my dental visit. Blue Cross of Alabama replied that I was going to be fully covered. So I proceed to visit my dentist based on my new insurance communication. The same happened on my second visit. Now Blue Cross sent a request to the dentist's office to return or pay back a portion of the coverage. My dentist's finance office communicated with them and said that it was an error from Blue Cross of Alabama, they incorrectly approved the visit with full pay, and they said they discovered my dentist was not in-network. But this is after the fact and they want me to pay for his error. The person that my dentist's office contacted name is ******, case number ************, phone number ************. I do not understand the reason to pay for others' errors and claim to get the full coverage, by Blue Cross sending a check to my dentist's office. Invoice attached.
Business response
05/24/2022

We are responding to your complaint concerning the refund taken on your dental claim for date of service May 11, 2021.

Claim number ********** was originally paid to Dr. **** ****** on June 17, 2021. We received a refund advising that they did not have a record of you being their patient. We repaid this claim under claim number *********** to Dr. J******* **** on March 31, 2022. We have one other claim on file which is from Dr. J******* **** for date of service November 17, 2021. It was paid on
December 16, 2021, under claim number ***********.

We hope this information is helpful.

Sincerely,

Customer Service

Customer response
06/02/2022
I am rejecting this response because: the claim is that they confirmed were on network, the dentist office informed me that after they accepted to cover 100% for the regular visit, lately they said the dentist is not in network and patience had to pay for out of network which means I need pay a portion. Blue Cross shield made an error, they need to pay for the error paying the difference from mentioned invoices
If they didn't say my dentist was in network, i was look for another dentist fully covered
Dentist still asking for $173 from my pocket. my phone ************ if they like talk to me
Business response
06/23/2022
Under the guidelines of your policy, if a non-DenteMax dentist is used outside of Alabama, benefits are paid according to the DenteMax PPO fee schedule. The patient is responsible for the difference between the billed charges and the fee schedule payment.

We reviewed the call made by Amelia from Dr. **** office to us on May 10, 2021. There was no mention of whether or not Dr. **** was in-network or not. ****** requested a breakdown of the benefits be sent to the office by fax, regarding if your contract had a missing tooth clause, does your contract downgrade, did you have waiting periods and if there was a healing period for American Dental Association code D4341. Our Customer Service Representative faxed the benefit breakdown of coverage, advised that there was no missing tooth clause, the contract does downgrade for posterior fillings and crowns, all waiting periods had been served and there was no mention of a healing period for code D4341. On page four of the fax sent to Dr. **** office, it explains in complete detail that you have a national dental PPO program. Outside of Alabama, benefits for DenteMax dentist are paid according to the DenteMax fee schedule and the patient is not responsible for the difference. If a non-DenteMax dentist is used outside of Alabama, benefits are paid according to the DenteMax fee schedule and the member is responsible for the difference.

We hope this information is helpful.

Sincerely,

Customer Service
Initial Complaint
11/18/2021
Complaint Type:
Service or Repair Issues
Status:
Answered
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
On 5/25/21 I had a c section. On 9/8/21 I had a non-diagnostic ultrasound for constant vaginal bleeding and pelvic pain. My doctor prescribed a CT scan. The insurance denied it and on 9/20 phone call they stated that "more elaborate urgent request" be sent. My provider did so 10/7. This was denied. The insurance denial included AIM specialty health guidelines stating this test is not medically necessary. Per AIM specialty health guidelines, the CT scan is recommended after non-diagnostic ultrasound.
Business response
01/24/2022
Business Response /* (1000, 8, 2021/11/30) */ AIM Specialty Health, an independent company, is contracted to review all request for imaging services. Based on our review of your providers request for a computed tomography (CT) Scan, we found that procedure code 74176 was denied twice as not medically necessary due to lack of information. A CT Scan should be used to look for the cause of pain after other tests have been done which did not explain the reason for the pain. The notes we received do not indicate other rest such as an x-ray, blood test or ultrasound were done prior to the request for a CT Scan. No appeals or Peer to Peer request were received. If your doctor has additional information that was not submitted, they are welcome to resubmit with additional information. We hope this information has been helpful. Sincerely, Customer Service Consumer Response /* (3000, 10, 2021/11/30) */ (The consumer indicated he/she DID NOT accept the response from the business.) This is the first time BCBS has claimed they have no record of an ultrasound. An transvaginal ultrasound was performed for my five months of vaginal bleeding and stabbing pelvic pain on 9/8/21. This ultrasound was billed to BCBS. Have they lost it? In the first denial, BCBS states "the notes do not show what condition you might have" and that this diagnostic test is "medically unnecessary" to help my doctor diagnose me. Nowhere does the denial state they have no record of an ultrasound. A call to BCBS after the denial, wherein I was told BCBS had "no record of why the denial was made" and I should "submit another more elaborate request". Why doesn't BCBS state that they had no record of the ultrasound, and pointlessly advise me to submit another request? Why has BCBS lost the ultrasound record? Why has BCBS keep no record of why a denial was made? Why does BCBS demand my doctor diagnose me with a condition prior to a required follow up advanced diagnostic imaging, in order to approve imaging? This makes no sense. A second prior authorization was done by my doctor, and that denial states "the notes do not show that the cause of your pain is unexplained". This is requiring my doctor to prove a negative, which is by definition impossible. Further calls to BCBS did not result in BCBS stating they had no record of the ultrasound. I am not responsible for BCBS lost records of the ultrasound, their inept way of handling records, their wrong advise on how to get the CT scan approved, and no one can prove a negative even though the insurance company demands my doctor does. I am not responsible for what the insurance company claims my doctor should write per BCBS denials: "show what condition I have" prior to diagnostic imaging CT, "do not show that cause of pain is unexplained" when ultrasound showed no cause of the pain. Per BCBS own medical guidelines, a screenshot provided by me on the first report to BBB, a CT scan is necessary for ongoing gynecology issues after a nondiagnostic ultrasound. BCBS clearly needs to find the ultrasound record from 9/8/21, which they have as it was paid for by them, and approve this medically necessary CT scan instead of telling me other lies about why the CT scan was denied.

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ComplaintsforBlue Cross Blue Shield of Alabama

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