Complaints

This profile includes complaints for Highmark Blue Cross Blue Shield's headquarters and its corporate-owned locations. To view all corporate locations, see Find Local Branches.

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• 

  Highmark Blue Cross Blue Shield

  120 5th Ave Pittsburgh, PA 15222-3000

• 

  Highmark Blue Shield, Inc.

  1800 Center St Camp Hill, PA 17011-1702

• 

  Highmark Blue Cross Blue Shield

  PO Box 890173 Camp Hill, PA 17089-0173

• 

  Highmark Blue Cross Blue Shield

  218 Summit Park Drive Pittsburgh, PA 15275

The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

• Initial Complaint

  Date:09/02/2022

  Type:Customer Service Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Have been trying to contact Highmark BCBS Pa for the past few days for an authorization for surgery. On 08/29/22 I waited on hold for 3 hours no one ever answered. On 08/30/22 I attemped to call again, on hold for 45 minutes, no one answered. Attempted to call again today and was on hold 3 hours and 31 minutes and again no one answered. Patient's surgery is 09/06/22 and will not have to be cancelled due to not being able to obtain authorization. I 've also tried to fax authorization request and they still will not answer. At this point I'm not sure what to do. All we're trying to do is take care of our patients. this is so sad.

  Business Response

  Date: 09/20/2022

  We are in receipt of your letter dated September 2, 2022, regarding the above referenced
  complaint.

  
  Please be assured that we have reviewed the record thoroughly in responding to this
  Complaint. Unfortunately, we are limited in our ability to provide the Better Business
  Bureau (BBB) with details of the provider service interactions due to protections detailed
  in privacy standards established under the Health Insurance Portability and
  Accountability Act (HIPAA).

  
  Nevertheless, we can confirm that we correctly informed the provider regarding coverage
  under the relevant group health plan. We also contacted the provider upon receipt of the
  complaint and confirmed what they had previously been advised.

  
  Should you have any further questions regarding the Complaint, please do not hesitate to
  contact me.

  
  Sincerely,
  Cassy M*****
  Grievance and Appeals Analyst
  Highmark Inc

  Customer Answer

  Date: 09/22/2022

  
  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. 
  
  Regards,
  *** ****

• Initial Complaint

  Date:08/29/2022

  Type:Billing Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  This unpaid claim is for Shingrix (Shingles Vaccine). I called BCBS 3x confirming that it will be covered. The reps give multiple excuses for why it wasn't paid. They commit to getting back to me and don't. There is no contact phone number for BCBS in the USA. They force you to speak with reps in the Philippines who can't speak or understand English. I asked to speak to a supervisor or a USA representative. They say there is none. This vaccine is covered by my plan. I should not be harassed or ignored in getting this taken care of. Please take care of this immediately or I will open a complaint with State of PA.

  Business Response

  Date: 09/20/2022

  We are in receipt of your letter dated August 29, 2022, regarding the above referenced
  complaint.

  
  Please be assured that we have reviewed the record thoroughly in responding to this
  Complaint. Unfortunately, we are limited in our ability to provide the Better Business
  Bureau (BBB) with details of the customer service interactions due to protection detailed
  in privacy standards established under the Health Insurance Portability and
  Accountability Act (HIPAA).

  
  Nevertheless, we can confirm that we correctly informed the member, but because of a
  coding issue, the claim denied. We are having it adjusted as an exception. Going
  forward when the member has a concern about the way a claim processed, he can file an
  appeal to our Member Grievance and Appeals Department at the address on EOB or by
  calling the phone number on the back of the member identification card. As part of that
  process, the member can seek relevant documents during the appeal and obtain relevant
  documents upon which the claim denial was based.

  
  Should you have any further questions regarding the Complaint, please do not hesitate to
  contact me.

  
  Sincerely,
  Cassy M*****
  Highmark, Inc.
  Executive and Regulatory Inquiries

• Initial Complaint

  Date:08/25/2022

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I submitted a Highmark, Member Submitted Health Insurance Claim Form on 6/13/22 to be reimbursed for an Inogen Portable Oxygen Concentrator that my doctor advised that I purchase due to having COPD. I paid $2810.00 out of pocket for the Inogen. After waiting 6 weeks I contacted Highmark to be told that there was insufficient information and that I would have to contact my health provider for the requested information. I was to upload the information on the Highmark Portal. I obtained the information 7/29/22 and uploaded as directed. I waited another week and called again to be told that I still needed additional information from Inogen. I submitted that information as requested via the portal for claim #***********. I since then have made numerous calls and messages through the portal to Highmark. I was then told to resubmit all the paper work again via mail and the portal because the initial claim was denied and another claim was opened claim # *********** and an adjustment would be made this was on 8/17/22. Today, 8/25/22, I looked at my claims standing and Highmark paid Wellspan my provider for the Inogen. I contacted Highmark and again was told that the claim was being adjusted and yet another claim # was being opened. After being on the phone and put on hold (one hour) I got cut off. I have done my due diligence to provide all the requested information yet still I'm not being reimbursed for the Inogen, Wellspan has been paid $126.64 and I was told by the Highmark associate that they would have to get Wellspan to refund the money. I am so frustrated that I have done so much work and still no reimbursement for the Inogen.

  Business Response

  Date: 09/14/2022

  This is in response to your inquiry sent on behalf of the member identified in Case ID
  ******** concerning his request for reimbursement for a portable oxygen concentrator.
  Our records indicate that Highmark received the member’s original claim submission on
  June 16, 2022. The member contacted Highmark on July 11, 2022, to check the status of
  the claim, and our Customer Service replied that it could take four (4) to six (6) weeks for
  processing, in addition to a ten (10) mailing period to receive an Explanation of Benefits
  statement. However, when the member contacted Highmark again on July 25, 2022, it
  was found the submission had insufficient information to process the claim. Typically,
  itemized statements include Patient Name, Identification Number, Provider Name, Tax
  Identification Number, Procedure Code(s), Diagnosis Code(s), and charge per item.

  
  The member sent in additional information that included a letter from his physician. The
  claim was sent for an adjustment on August 18, 2018, but the adjustors entered the
  incorrect provider information. They listed the physician’s office at the billing provider,
  and the claim processed a payment to the physician’s office in error. Please note that a
  new claim has been entered and is currently in process. Since the durable medical
  equipment provider shows as an in-network provider, contractually Highmark is
  obligated to pay the provider our in net-work allowance. Once the provider received our
  payment with the provider statement, they should reimburse the member his payment that
  he paid directly to them. The member may also want to forward a copy of his
  Explanation of Benefits statement to them once he receives it.

  
  If the member has any questions concerning this coverage, please have him contact our
  Customer Service Department at ###-###-####. If you have additional questions,
  please contact me directly.

  
  Sincerely,
  Margueritte M**************
  Executive Legislative Inquiries

  Customer Answer

  Date: 09/19/2022

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  

  
  

  Highmark has paid Wellspan and not me and I should not be the one that has to chase down my money.  Highmark should void the payment to Wellspan and reissue to me.  I have attached the copy of the invoice that clearly states I made full payment to purchase the equipment.  My provider only advised that I purchase the equipment they did not purchase for me.
  
  Regards,
  *** *********

• Initial Complaint

  Date:08/15/2022

  Type:Billing Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I am a Highmark Medicare Advantage customer. I always date stamp my incoming mail. I received my July 2022 statement for insurance June 16, 2022 in the amount of $25.00 due July 1, 2022, I always pay three months in advance or $75.00. I placed my $75.00 payment in the mail June 23, 2022. I received a past due notice July 13, 2022. **** ****** never receives a past due notice. Obviously, my payment has been lost in the mail. I am told by Highmark late payments can terminate my health insurance coverage. On July 25, 2022, I directed a letter (copy attached) to Mr. Daryl V****, Senior Vice President and Chief Financial Officer at the Highmark headquarters located at 5th Avenue Place * 120 5th Avenue * Pittsburgh, PA 15222 along with a new check number **** for $75.00. Stop payment checks for oldsters are expensive and I am not issuing another check. I have left messages for Mr. V*****'s office August 8, 2022; August 5, 2022; August 3, 2022 with a phone number 412 – 544-7711 and none of my calls are addressed. I reiterate I am not going to issue a third check. Where is check number ****? 
  Please promptly investigate. 
  
  

  Customer Answer

  Date: 09/01/2022

  Re ******** and this is an addendum to my August 24, 2022. 

  
  Morgan called August 24, 2022 from Highmark (Scranton, PA) as outlined in my August 24, 2022 correspondence and asked me a couple questions. She questioned where did I mail the check in question #****. I replied I used the coupon address that accompanies my statement. She continues to claim this has been paid. I spoke with my customer contact Sherry at Citizens/Main Office in Washington, PA and she reiterated that check #**** has not been paid and my account reads on 'HOLD' screen 'DO NOT PAY CHECK #**** TO HIGHMARK.' Morgan also asked me to obtain my checkbook and read to her my next check number which I concurred. How audacious! I do not think Morgan believes me when I mailed another check number **** to their corporate headquarters. I cannot begin to imagine what transpired to that letter and check; the check was stapled to the correspondence. 

  
  Sincerely, 
  

  **** ****** 
  

  
  

  Customer Answer

  Date: 09/07/2022

  Morgan from Highmark called August 19, 2022 for a grievance check. She is located near Scranton, Pa. Her phone number is ###-###-####. She stated my check number **** was cashed August 10, 2022 and was paid for in the amount of $75.00. However, that is not the check in question if you can refer to my correspondence addressed to the BBB dated August 11, 2022, (copy attached.) She indicated my account is paid in full to date. She is looking into the whereabouts of my letter and check number **** addressed to Mr. V**** (copy attached.) My big question at the moment in this dispute is where is check number #****? 

  
  ****** at Citizens Bank indicated the original check number **** was a "Stop Payment" check dated July 18, 2022 and no payment can be made. 
  

  Sincerely, 
  

  
  **** ****** 
  

  
  

  Business Response

  Date: 09/07/2022

  This is in response to your inquiry sent on behalf of the member identified by Case ID
  ********.

  
  The member is currently enrolled in a Complete Blue PPO plan with an effective date of June
  1, 2021 with no end date. Review of the plan internal system shows that a payment of $75.00
  for check number **** applied to the member’s account on August 10, 2022.

  
  Further review of the member account shows an invoice was issued to the member on June 6,
  2022 with the premium amount of $25.00 due on July 1, 2022. When a premium payment was
  not received, a delinquency letter was issued to the member on July 13, 2022. The letter advised
  that the premium was not received as of July 1, 2022 if the payment is not received by
  September 30, 2022 the member will be disenrolled effective October 1, 2022.

  
  We received the complaint on August 19, 2022 for review. The member became concerned
  when she received a past due notice of a premium not received. The first check number ****
  was dated June 23, 2022 and mailed on June 25, 2022. She did not know why she was receiving
  a past due notice in the mail on July 13, 2022 when she mailed her premium payment. It was
  then determined with the post office that her mail was lost at that time and other checks to
  different companies also did not get to the payment destination. Member went to the bank to
  stop pay on the first check issued, this was the result for the member to write another check.
  The member wrote another check, check number ****. Plan records reflect the receipt of check
  number **** applied to the member’s account on August 30, 2022.

  
  The member’s invoices advise to please submit payment to Complete Blue PPO P.O. Box
  382178 Pittsburgh, PA 15251-8178. The member researched Mr. Daryl V****, Senior Vice
  President and Chief Financial Officer at the Highmark headquarters to send her second
  premium check. With the member not sending to a corresponding address for premium
  payments it delayed the payment processing. The plan reports information that is reflected
  within in our internal systems as we do not have access to the banks record.
  
  The plan contacted Ms. ****** on August 24, 2022 to gather additional information to complete
  due diligence to address the member’s concerns. She was understanding and happy with the
  resolution. In conclusion, the member is actively enrolled and her account is paid in full with
  no past due balance.

  
  If the member has any questions concerning this coverage, please have her contact our
  Customer Service Department at ###-###-####. If you have additional questions, please
  contact me directly.
  
  Sincerely,
  
  Morgan * Y****
  Executive Legislative Inquiries

  Customer Answer

  Date: 09/08/2022

  
  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. 

  Morgan from Highmark contacted my August 30, 2022 and stated they honored the Stop Payment of Citizens check number **** (the original check in question.) The second check number **** directed to Mr. Daryl V**** was located and they are processing this for payment. My account is paid in full. I asked Morgan of the three phone calls I made to ###-###-#### why did someone not call me? She indicated that person was on an extended leave. I then stated someone should have been accepting these calls. She did not answer. 

  
  I had all the ammunition required to prove my point check number **** was a Stop Payment check and I would not have to file a complaint with BBB. 

  
  Highmark apparently had to prove their point. Sometimes it is best to listen to the individual issuing the complaint for verification! I can say this claim with BBB has been resolved, 
  Thank you for all your assistance in this Claim. 

  
  Sincerely,  
  
  **** ******

• Initial Complaint

  Date:07/21/2022

  Type:Customer Service Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Let’s start from the top Key points. I not only just got done having Covid but just found out I was pregnant. I was told for many years that because I have a couple uterine issues that having children would be very low and very difficult, even though I’m young, my body may never let me produce what I need to have and/or carry one. Boom. I’m finally pregnant. My insurance changed a couple months back because I turned 26 from highmark blue cross blue shield to highmark whole care. I was advised in MAY with the rep who enrolled me that everything will stay the same. I go to get blood work from quest, they tel me my insurance changed who can do my blood work. I call highmark and wait 4 minutes to get to a human after dealing with entering my information with their robot system. Then when the rep answers, she asks me for the same exact information and I immediately ask for a supervisor. Not only am I Currently not medicated for my depression ptsd and anxiety, I just quit cigarettes, just had Covid and just found out I’m pregnant and bleeding and may lose my child and need my blood work to help figure it out. My rep insisted on getting on my nerves to the point of me yelling at the top of my lungs, and yes my behavior was atrocious but I still was never given a supervisor , she went back and forth with me, got smart with me, declined a supervisor because “they will tell you the same thing”. It doesn’t matter. In the state of PA a person can sue for “negligent infliction”. I told my rep I would contact state and BBB and that’s what I’m doing. She told me “go right ahead”.

  Business Response

  Date: 07/29/2022

  Per your letter, you reference a complaint was submitted on the behalf of ******* ******* on July 21, 2022. Highmark Wholecare would like to apologize for Ms. ********* experience and frustrations. 

  According to Ms. ********* complaint, she stated when she enrolled in Highmark Wholecare she was told everything will stay the same as her commercial insurance. 

  Please know The Department of Health and Human Services does not permit Highmark Wholecare to market or sell our Medicaid plan. All enrollments are sent through the Enrollment Assistance Broker, Maximus. Maximus is available to assist recipients in plan selection by sharing benefits, providers and other plan information. Therefore, we cannot comment on what Ms. ******* was told at the time of her enrollment, this is not our jurisdiction. 

  Ms. ******* states she waited four minutes to get a human after dealing with our robot phone system. Ms. ******* mentioned when she spoke with a human, they asked the same thing the system had already asked. 

  Please know at this time we are unable to verify Ms. ********* wait time, but we do have an automatic system, when calling you are to enter your information. However, please know there was a system issue and the member's information did not populate upon the call being answered. 

  Therefore, the Customer Service Representative (CSR) asked the member to verify her name, demographics, and the reason why she was calling, 
  Health benefits or health benefit administration may be provided by or through Highmark Wholecare, coverage by Gateway Health Plan, an independent licensee of the Blue Cross Blue Shield Association ("Highmark Wholecare"). Highmark Wholecare offers HMO plans with a Medicare Contract. Enrollment in these plans depends on contract renewal 
  

  Ms. ******* reference she asked for a supervisor, but was not given one and told the supervisor would tell her the same thing. 

  The member's call was listened to and reviewed. The records show the member was not willing to confirm who she was and to tell the CSR what her issues were before sending the member to a supervisor. When the CSR was asking to confirm whom she was speaking with and what the member's issue was the member was speaking very loudly, verbally abusive, using foul language towards the CSR. 

  The member finally explained the issue and the CSR tried to assist the member with her issue regarding an in-network lab. The member was not forwarded to a supervisor and the CSR will be coached. Please be aware, the supervisor would have given the same information the CSR gave the member. Please note, we have spoken to the member and she did have her lab work completed. 

  Ms. ******* stated she told the CSR she was going to call the BBB and the CSR told her to go right ahead. 
  After listening to the call, the records show the member told the CSR she was going to call the BBB, but the CSR did not respond to that statement. The CSR tried to further assist the member with her issue. 

  Lastly, Ms. ******** mentioned the CSR did go back and forth with her and got smart with her. 
  As stated above the call was listened to and reviewed and after being verbal abused by the member the CSR did try to assist the member with the in-network lab issue. There was some going back and forth, because the CSR was trying to assist the member with her issue. There was a time during the call the CSR was not completely professional, please know the CSR will be coached. Highmark Wholecare will continue to monitor. As stated above, we have since spoken with Ms. ******* and she confirmed she had completed her bloodwork. 

  Again, Highmark Wholecare apologizes to Ms. ******* for her experience and her frustration. 

  If you should have any further questions or concerns, please call, Toni M**** at ###-###-####. 

  
  Sincerely, 
  Toni M**** B********* Senior Quality Analyst Appeals & Grievances 
  

  
  

• Initial Complaint

  Date:07/20/2022

  Type:Customer Service Issues
  Status:

  ResolvedMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I have been unsuccessful trying to contact Highmark BCBS of WNY by phone and email for last five business days. I have called the phone number on my insurance card ###-###-#### and on each attempt the call ins answered by a pre recorded message then placed on hold greater than 30 minutes each call. After 30 minutes I give up assuming my phone call will not be answered. In as may days I completed the contact form on Highmark BCBS website and have yet to receive a response. I'm hoping the BBB has a way to contact Highmark to inform them that their telephone and online contact is not being answered.

  Business Response

  Date: 08/15/2022

  Hello:
  
   
  
  From our Senior Customer Service Representative regarding the above complaint:
  
   
  
  I have reached out to this member but the call went to voicemail. I left a message with the phone number for Individual Products. The last ID card sent to the member had the incorrect phone number listed so I will be ordering him a new card. I was able to find the e-mails he mentioned in the complaint and will be replying to those by e-mail.
  
   
  
  Thank you.
  
   
  
  Sue
  
   
  
  Manager | Member Service
  
  Highmark Western and Northeastern New York
  
  
   
  

  Customer Answer

  Date: 08/15/2022

  
  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. 
  
  Regards,
  ******* ******

• Initial Complaint

  Date:07/08/2022

  Type:Customer Service Issues
  Status:

  UnansweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  1/20 representative told me about claim 2/9 representative told me the entire bill will be adjusted 3/30 representative told me entire claim will be adjusted with 30-60 days 4/21 representative told the claim will expedited to management and adjusted 5/6 representative told me they would email accounts and take care of claim Next weeks I have contacted them daily only to be lied to and the claim still is not been paid. Natura continues to send me bills. Sue S***** and Jamie s have been the supervisors working on this. Sue has attempted to solve this but hs been out of the office and on vacation and no one else has been any help. Jamie s has lied on multiple occasions telling me she would call me back never calls back. She tells me she will contact a supervisor never does. I need this claim resolved as it had been going on since January.

• Initial Complaint

  Date:06/21/2022

  Type:Service or Repair Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  I went to fill my medication at the same pharmacy me and my husband has always uses They filled his but said I was locked into a another pharmacy well I checked the website and Walmart ran it and 185 dollars Whr as last month it was 95 dollars Then I look down and there the pharmacy went and filled a claim on the same meds that we both filled at a different pharmacy because Walmart didnt have enough last month to fill them so we had to use a different pharmacy And they have me filling the same meds twice last month One at the pharmacy that actually filled them a d Walmart for 185.00 if the sane meds And we didn't even use Walmart to fill them on 5-20-22 I don't understand why all of a sudden my coverage changed and its been the same since up until last month I mean what I. The world dies it mean to be locked into a pharmacy We are moving and this is crap I cant help thar my pharmacy doesn't carry my pain management drug Thats not my fault And have me on mail delivery Told me to call CVS pharmacy they were my specialty pharmacy and CVS told me Well sorry we aren't taking anymore suboxone patients So I can't afford to pay 185 dollars at Walmart when I paid 95 last month And it's just bull I think it should be ur choice whr u go to get ur meds Not ur insurance company Because we pay it every month Its just not rg and now we are moving Abd I dint hv my meds Because I'm locked in to a pharmacy that's RIDICULOUS I MEAN RIDICULOUS They shouldn't be able to do that Its not rg They hv to do what we the members want to do We get a list of our pharmacys and use them and then we can't Its all bullshit B excuse I hv to hv the meds that I can't afford just because I had another pharmacy there pushing me And it's because they don't care my pain management meds I had to go smehere else and that's not my fault But I'm bring pushed.

  Business Response

  Date: 07/07/2022

  This is in response to your inquiry sent on behalf of the member identified by Case ID
  ********.

  
  The member is currently enrolled in a Highmark Preferred Provider Organization (PPO)
  plan through a self-insured employer group with an effective date of August 1, 2021.

  
  Under the terms of Highmark’s contract with a self-insured group, we must administer
  health insurance benefits in strict accordance within the terms of their benefit program.
  Highmark provides the Designated Pharmacy Program which is designed to offer support
  to our members by managing certain prescriptions through one pharmacy. This member
  was notified of the program via a letter dated May 13, 2022, which advised the reasons
  for and benefits to this program. A review of the member’s prescriptions assisted in the
  program’s selection of a specific pharmacy as being her designated pharmacy. However,
  this letter also indicated that if there was a preferred pharmacy that the member would
  want to use, they could call the number provided to discuss options. If the member is not
  satisfied with the choice selection, she may call ###-###-#### to discuss a change or
  request a secondary/back up pharmacy.

  
  If the member has any questions concerning this coverage, please have her contact our
  Customer Service Department at ###-###-####. If you have additional questions,
  please contact me directly.

  
  Sincerely,
  Margueritte M**************
  Executive Legislative Inquiries

• Initial Complaint

  Date:06/16/2022

  Type:Billing Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  Good afternoon: Dr. ******* is an out of network provider with Blue Cross. The attached surgical claim has been grossly underpaid. Blue Cross can not confirm the out of network rate for this plan whether it's UCR, Fairhealth. etc. After numerous attempts to have this claim paid correctly, we are now filing a complaint against Blue Cross for ******* *******, 9/1/21. We have attached a copy of the summary benefits, claim No. ***********. Kindly reprocess accordingly. Thanks!

  Business Response

  Date: 06/30/2022

  This is in response to your inquiry sent on behalf of the provider office identified in the
  above listed Case ID ********, and the pricing applied to the claim in question.

  
  The patient is currently enrolled in a Highmark BlueCare Custom Preferred Provider
  Organization (PPO) plan through an employer group. This fully insured nongrandfathered group has one level of appeal to be administered by Highmark with an
  external review available for medical necessity denials only.

  
  The member’s claim was processed through the BlueCard program. This is a program
  that is designed to allow Blue Cross Blue Shield plans to share participating provider
  discounts and allowances with other Blue Cross Blue Shield Plans. This program is also
  designed to hold members harmless for the difference between a participating provider’s
  charge and the allowance. Claims are submitted to the provider’s local Blue Cross Blue
  Shield Plan. The local plan is considered the host plan and is responsible for pricing,
  allowances, transmitting the claim to the home plan and payment to the provider. As the
  home plan, Highmark verifies membership eligibility and benefits and transmits the claim
  back to the host plan for payment.

  
  Please consider that nonparticipating and/or out of network provider claims may also
  process via this system. However, these providers do not have a contract with the
  local/host plan and do not have to accept any plan allowances. They may bill the member
  the total charge of the claim. As indicated above the local, or host plan is responsible for
  pricing, and the claim on file indicates these services were submitted to Highmark with
  pricing from the local/host plan. Questions regarding pricing should be directed to the
  provider’s local Blue Cross Blue Shield plan.

  
  If the provider has any questions concerning this coverage, please have them contact our
  Customer Service Department at ###-###-####. If you have additional questions,
  please contact me directly.

  
  Sincerely,
  Margueritte M**************
  Executive Legislative Inquiries

• Initial Complaint

  Date:06/11/2022

  Type:Billing Issues
  Status:

  AnsweredMore info

  Complaint statuses

  Resolved:

  The complainant verified the issue was resolved to their satisfaction.

  Unresolved:

  The business responded to the dispute but failed to make a good faith effort to resolve it.

  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.

  Unanswered:

  The business failed to respond to the dispute.

  Unpursuable:

  BBB is unable to locate the business.

  On 12/03/2020 I received surgery, at which point the anesthesiologist that billed was considered out of network. The claim was settled for the amount of $500.03 according to the EOB. On 1/27/2021 I received a check in the amount of $500.03 with instruction from Highmark to use the money to pay the bill once received from Capital Anesthesia Solutions of Philadelphia, LLC. On 5/25/2021 I received the bill from Capital Anesthesia Solutions of Philadelphia, LLC and paid in full the $500.03. On 7/17/2021, the payment was adjusted to $610.20 and apparently the provider was now in network, so Highmark went ahead and sent the full $610.20 to Capital Anesthesia Solutions of Philadelphia, LLC directly for payment, despite only $110.17 being owed (as $500.03 was previously paid out). Highmark then sent a letter to me explaining the overpayment of $500.03 and that I was responsible to pay this back. I called and spoke to a representative who stated that there is no payment owed on my account. I received another letter in September stating the same thing, and called back and again was told there is no payment owed on my account. I received a call earlier from a collections agency that my account is now in collections for the $500.03. Since Highmark overpaid the provider and multiple representatives told me there was no balance owed, Highmark should request the overpayment refunded directly from the provider.

  Business Response

  Date: 07/12/2022

  We are in receipt of your letter dated June 13, 2022, regarding the above referenced
  complaint.

  
  Please be assured that we have reviewed the record thoroughly in responding to this
  complaint. Unfortunately, we are limited in our ability to provide the Better Business
  Bureau (BBB) with specific claim details due to protections detailed in privacy standards
  established under the Health Insurance Portability and Accountability Act (HIPAA).

  
  Nevertheless, we can confirm that we have informed the member that the issue has been
  reviewed. All parties involved in the complaint have been contacted and an amicable
  resolution has been achieved. The member has been given contact number information
  for any future questions or concerns.

  
  Should you have any further questions regarding the complaint, please do not hesitate to
  contact me.

  
  Sincerely,
  Cassy M*****
  Grievance and Appeals Analyst
  Highmark Inc.