Business ProfileforHealthfirst Inc., Claims Dept.

This complaint is against Healthfirst for failure to promptly pay valid claim submitted within timely filing on 10/15/21 and properly investigate denied claim. We received denial notice on 11/03/21 for reason "service requires authorization". Prior to rendering services , we obtained approval notice via Evicore on 08/21/21 under plan reference number***********. Upon denial notice, we submitted a request for review and reconsideration for the incorrectly denied claim on 11/10/21. On 11/12/21 we called Healthfirst Provider Services. Representative Patrick Q confirmed that the claim was "denied wrongly" and supervisor Xander P confirmed that there is a valid auth on file, under call reference# ********. On 11/18/21, we submitted a complaint to Department of Financial Services (DOF) under Provider Complaint Case: *****************. DOF responded that they do not have jurisdiction to intercede and provided agency information for Centers for Medicare and Medicaid Services for further assistance. On 11/23/21, we sent written correspondence to our Healthfirst provider account representative, Ms.Lisseth A******, and have not received a response to date. Our correspondences are typically ignored by the health plan. On 12/08/21, the health plan maintains that services require authorization and falsely states that we have exceeded authorized units on response letter dated 12/08/21 signed by Christine L********, Vice President of Regulatory Affairs. On 12/14/21, we sent a written correspondence to letter 12/08/21 and again submitted our valid authorization that they continue to ignore. On 01/13/22 we received by mail notices dated 01/03/22 and 01/06/22 that the health plan upheld denial of our valid claim based on reason "service(s) were not authorized". Upon receipt of upheld denial, we submitted a 2nd appeal and again submitting our valid authorization. These wrongful denials are a systemic problem of the health plan that we have encountered many times.