ComplaintsforHealth Plans Inc

• Initial Complaint

  02/06/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I was covered by MyQHealth under Health Plans Inc for medical insurance during my time working for ******************** LLC. I began seeking treatment for TMJ problems around December 2020. I sought treatment at ************************. (*****) I had TMJ coverage under my plan. It was determined in my treatment plan that I needed an oral appliance. However when the claim was submitted to insurance my insurance denied coverage for the appliance saying that it was not medically necessary. The ***** filed an appeal twice on my behalf and I went back and forth with the billing of ***** as well as Health Plans Inc.(HPI) HPI continued to say it was still reprocessing the claim months later. I received a letter from an appeals coordinator for My Q Health under HPI stating the original decision was overturned and the appliance would be covered in early July 2021. I have attached the letter. However, the ***** never received any more communication from HPI/ the updated claim. Since then I have gone back and forth with HPI as to why it was not paid out. *** said the appeal was denied since it did not happen in a timely fashion yet I have the letter from the appeals coordinator that it would be covered. I called and spoke with them monthly. When I shared the letter with HPI in 2022 suddenly it became an escalated matter and they assured me that it would be paid and management was working to find a solution. I continued to call monthly and just heard the same thing. In January 2023, I found out that Medwatch would be taking over all plans from HPI. I have been in contact with them recently and they are now saying again the claim was denied and would not make payment because the coding was incorrect. I have been back and forth for this claim for almost 2 years exactly and there is no solid resolution. I receive a balance bill from the ***** for ****+ each month and have stopped pursuing further treatment from them because they want me to pay or contact my insurance each time.

  Customer response

  02/17/2023

  [A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
  
  Better Business Bureau:
  
  I have reviewed the response submitted by the business and have determined that the response does satisfy my issues and/or concerns in reference to complaint #********. I understand that by choosing to accept the business response that my complaint will be closed as resolved. I received a phone call from the representative from MedWatch on 2/10/2023 that HPI was going to have the claim adjusted to honor the Quantum appeal. It will be reprocessed. I have attached additional correspondence I received that week from MedWatch.

  
  Regards,
  
  ******************************

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