ComplaintsforUPMC Health Plan

• Initial Complaint

  09/17/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Ok every year though **** give $ 165 in rewards on our health benefits card you get $30 for your yearly wellness exam you get $ 25 for your diabetic eye exam you get $ 50 for your annual breast mammogram and if I'm not mistaken you get $ ******************************************************************************** a stool sample to a lab to check for colon cancer well i did my eye exam got my money for that got my rewards for my yearly wellness exam but in June when I had my sonogram mammogram due to a messed up rotator cup surgery I call my ** to set up the sonogram mammogram upmc said that was fine but the ************************** billed it wrong they billed it as a Diagnostic instead of a preventive so upmc call me on 9-7-24v and told me that they would call ****************** billing to have them resubmit it as a prophylactic but they have still to do it i called today and was told that they have to investage it but i don't know what the ** *** look at my test after my mammogram said there was no signee of cancer i never have had breast cancer i get checked ever year and every single one of my mammograms come back negative for cancer so i don't know what there to investigate now they say i have to wait another ***** days iv all ready waited almost 4 months this is not fair because ****************** sent in the wrong code not there are refusing to call the hospital to fix it

  Business response

  09/27/2024

  UPMC Health Plan****** ("UPMCHP") has received and reviewed your letter dated September 17, 2024, as well as the accompanying complaint. 

  
  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected individual is a ****** member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 

  
  Should you have any further questions, please contact me at ************.

  
  Respectfully Submitted, 
  
  "*******" ******** **, Esq. 
  Staff Attorney 
  UPMC Health Plan 
  

  
  

• Initial Complaint

  09/13/2024

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  why does my health plan not pay for my full dental plan as it was months ago. UPMC sent me a bill for over $1056.00 for my dental and they want me to pay the rest but I can not pay the whole bill. Is there a reason for UPMC to not pay my full amount of my dental bill completely. Will you find out why UPMC can't pay my whole bill completely instead sending me this big bill. Please help me get this bill off my back with my health insurance with UPMC for life company, Thank you for your help

  Business response

  09/23/2024

  UPMC Health Plan, Inc. (“UPMCHP") has received and reviewed your letter dated September 13, 2024 as well as the accompanying complaint. 

  
  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 

  
  Should you have any further questions, please contact me at ###-###-####. 

  
  Respectfully Submitted, 

  Ashton H*****, Esquire Staff Attorney UPMC Health Plan 
  

  
  

  Customer response

  09/24/2024

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

• Initial Complaint

  10/10/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I have told UPMC for Life numerous times at every address that I have lived at since 2016 that I am not eligible for Medicare and to stop mailing me advertisements for them. They have followed me to every address. I would like for this to stop and actually have them listen to me!

  Business response

  10/18/2023

  UPMC Health Plan, Inc. (“UPMCHP") has received and reviewed your letter dated October 11, 2023, as well as the accompanied complaint filed by **** ***********. Mr. ***********'s complaint relates marketing materials received from UPMC for Life,' UPMCHP's Medicare Advantage product. Our enrollment records indicate that Mr. *********** is not currently enrolled in a health insurance product offered by UPMCHP. 

  According to Mr. ***********'s complaint, he has been receiving unwanted marketing materials related to UPMC for Life since 2016. He further states that he is not eligible for Medicare and has requested not to be contacted by UPMC for Life. This matter was referred to the UPMC for Life Marketing Department and they have confirmed that Mr. ***********'s name and the address listed in the complaint have been placed on the "Do Not Contact" list in the UPMC for Life mailing database as of October 16, 2023. 

  Please note, the UPMCHP is only able assist with the suppression of mailings that originate from within the UPMC Insurance Services Division. UPMCHP is unable to stop materials being sent by other UPMC entities or departments outside of UPMCHP. UPMC is an integrated delivery and finance system (IDFS) that is made up of multiple divisions, as well as many different medical professionals, providers, hospitals, doctor's offices, and outpatient facilities. If Mr. *********** receives any future unwanted mailing, we request that he provide us with the sender's return address. This information will help to identify the source of the mailings and assist in directing his request to the appropriate party to prevent future mailings. 

  Should you have any further questions, please contact our department. 

  Respectfully Submitted, 
  

  Steven *. V***** **** 
  Staff Attorney 
  

  
  

  Customer response

  10/18/2023

  [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 made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. 
  
  Regards,
  
  **** ***********

• Initial Complaint

  08/28/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  November 2022 I got approved for Waiver/Midas program for the disabled and underfunded US citizens. They cover Medicare/Medicaid premiums, issue a Health Care Coordinator for any and all concerns. Since February of 2023 I have had an infection that started in my tooth which they knew about but could not find me Dental care. I have been on antibiotics since. The infection is now in my blood through out my body. I asked for a Home Health Care aid. That took 3 months. My aide left for a month or so but I had no back up. Some times, here and there, someone would show up but mostly on my own. I'm in a wheelchair, 3 back surgeries, Neck surgery, osteoarthritis through out my body, migraines, enlarged heart, high blood pressure, high cholesterol, COPD and a form of MS. Spinal Stenosis and now, unusual bleeding where I shouldn't be. I got approved 25 hours a week for a HHCA but required more because of all the medical issues and emotional support getting back and forth to my appointments. They gave me 5 hours more, I asked for UP TO 50, just in case. Got denied. Requested another assessment for 40hrs per week. Still waiting. An automatic door lock was too be installed 4 months ago. Still waiting. My PCP along with myself requested medication for weight loss. I'm overweight, bad heart and lungs with high cholesterol and even my brother has Diabetes, not to mention I can't exercise in a wheelchair, dizzy, nauseous, migraines and can't breathe very well. No. Denied. My mom died the same age I am now. I've barely been out of bed since January, Feb of this year. I'm still waiting to get to a Dentist that won't refuse to work on me because, " UPMC doesn't pay for anything." Sent me home.

  Business response

  09/15/2023

  UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated August 29, 2023 as well as the accompanying complaint. We are also in receipt of the HIPAA authorization form on September 13, 2023. 

  UPMCHP's enrollment records indicate that at all relevant times Ms. ***** was a participant in UPMC Community HealthChoices ("UPMC-CHC”), a Community HealthChoices Managed Care Organization (“CHC- MCO") and product of UPMC for You, Inc. Community HealthChoices (“CHC”) is Pennsylvania's Medical Assistance (Medicaid) managed care program that includes physical health benefits and long-term services and supports (LTSS). Ms. ***** is also a member of UPMC for Life Complete Care, a dual-eligible Special Needs Plan (D-SNP) and a product of UPMC for You, Inc. In her complaint with your office, Ms. ***** expresses frustration with several coverage issues. 

   

  Issues with Dental Care

  On March 22, 2023, Ms. *****'s service coordinator contacted UPMCHP Member Services for assistance in locating an in-network dental provider for Ms. ***** under her D-SNP plan. The service coordinator was provided the names of several dentists. On March 27, 2023, Ms. ***** contacted UPMCHP Member Services for assistance in locating a dental provider and was given the name of a dentist that was in network. 

  On August 2, 2023, Ms. ***** contacted UPMCHP member services to locate an in-network endodontist, and an endodontist within 50 miles of her home could not be located. The member was offered an organization determination under the D-SNP plan, and the member declined. 
  

  On August 8, 2023, Ms. ***** contacted member services to locate an endodontist, and was again informed that there was not one within 50 miles of her home. 
  

  On August 29, 2023, Ms. *****'s service coordinator contacted UPMCHP's Member Services to ask about Ms. *****'s benefits for out-of-network dental services. The service coordinator was informed that the member would have to contact UPMCHP for an organization determination. 
  

  On August 30, 2023, the service coordinator contacted UPMCHP on behalf of the member to request an out-of- network organization determination. No action was taken on that call. 
  

  Our records indicate that Ms. ***** visited Dr. Siddhant Gaidhane of Sadler Health Center Corporation on September 6, 2023, who is an in-network provider. Should Ms. ***** experience further difficulty, we encourage her to contact Member Services for assistance. 
  

   

  Issues with Medication 
  

  Ms. ***** notes that her coverage was denied for a weight loss medication. On March 10, 2023, Ms. ***** filed an expedited coverage determination under her Medicare plan for Wegovy. The coverage determination was denied on March 10, 2023 because Wegovy is not covered under Medicare Part D for the treatment and maintenance of weight loss. Section 1927(d)(2) of the Social Security Act specifically excludes from coverage drugs "used for anorexia, weight loss, or weight gain". As noted in Chapter Six of the Medicare Prescription Drug Manual, "Part D drugs do not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1927(d)(2) of the Act." This includes drugs "used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity))." 
  

   

  Issues with Home Care 
  

  As a participant with UPMC Community Health Choices, Ms. ***** receives personal assistance services ("PAS"). On July 12, 2023, Ms. ***** requested an increase in her current number of PAS hours from 25 hours per week to 50 hours per week. After review by a medical director, UPMCHP granted 30 hours of PAS, and denied 20 hours because Ms. *****'s assessment determined that her functional needs would be met with 30 PAS per week. On July 13, 2023, Ms. ***** filed an appeal, requesting additional PAS hours. On August 11, 2023, UPMCHP issued a decision upholding the 30 hours of PAS a week. The letter includes all the information relevant to filing a request for an external review and/or a Fair Hearing with the Department of Human Services. 
  

   

  Issues with Automatic Lock Door 
  

  Our records indicate that the request for the automatic door lock was approved on September 8, 2023. If Ms. ***** has not received notice of this approval, we encourage her to contact her Service Coordinator. 

   

  Should you have any further questions, please contact me at  ************. 
  

  Respectfully Submitted, 
  

  Lakshmi D****, Esquire 
  Assistant Counsel 
  UPMC Health Plan 
  

  
  

• Initial Complaint

  04/11/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Upmc has reported me to collections for a bill that I have proof, I paid at the time of service. $20 copay 5/25/21. Upmc misappropriated $17.50 of the $20, to I don’t know what. They also added this account # ************** to a payment plan from a procedure, that has also been paid in full. My records, now show, I have paid this acct twice. I have been in contact with them multiple times over the last two years, with no resolution. Today, I received notice that they have turned this bill to collections.

  Business response

  04/27/2023

  UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated March 12, 2023 as well as the accompanying complaint. 

  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 

  Should you have any further questions, please contact me at ************. 
  

  Respectfully Submitted, 
  

  Steven *. V****, Esq. Staff Attorney UPMC Health Plan 

  Business response

  05/03/2023

  UPMC Health Plan, Inc. (“UPMCHP") his in receipt of your fax dated April 27, 2023 containing a HIPAA- compliant authorization form signed by complainant *** ******. As such, we can now offer a full response to your letter dated April 12, 2023 and accompanying complaint. Ms. ******'s complaint relates to UPMC provider billing. 

  UPMCHP's enrollment records indicate that at all relevant times Ms. Folino was enrolled in a UPMC Gold Advantage Exclusive Provider Organization (EPO) plan, a self-insured health plan offered by the UPMC ********** ******. UPMC Benefits Management Services, an affiliate of UPMCHP, provides certain third-party administration services to the group health plan. As a self-insured plan, member-related appeals are governed by the Employee Retirement Income Security Act (ERISA) and its related regulations, and all final coverage determinations are made in accordance with ERISA and the group's plan documents. 
  

  According to the letter received from your office, Ms. ******'s complaint is directed against a UPMC provider. As a courtesy, UPMCHP has forwarded this complaint to UPMC Health Systems. However, UPMCHP can offer the following information. 
  

  According to UPMC Billing, $17.15 of the $20 paid by Ms. ****** was applied to an outstanding February 3, 2021 bill. Unless otherwise requested by the patient, a payment made to UPMC will be applied to the oldest outstanding charge. UPMC Billing advised that while they could apply the $20 payment to the March 25, 2021 copayment, Ms. ****** would still owe $17.51 on the February 3, 2021 charge. Ms. ****** should contact UPMC Billing directly inorder to clarify payments going forward. 

  Should you have any further questions, please contact me at ************. 
  

  Respectfully Submitted, 
  Steven *. V****, Esq. Staff Attorney UPMC Health Plan 

  Customer response

  05/03/2023

  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.
  

  I have read UPMC response. I have a long history of communicating with the health plan and billing departments on this matter. I am aware of past practices done without patient knowledge. I tried multi times to correct this. They were to reverse their reappropriating my payment. They did not. I then noted, the account had been added to a payment plan, that has been paid off. I have been unable to resolve it. My documentation says I have paid this twice, as indicated on the documentation included in the original complaint.  UPMC has turned it to collections. I will wait for further communication from the forwarding, as indicated in the response.

  I do have a concern that may interfere with the investigation. I appears UPMC as placed **** ******s' name in place of mine a the body of their letter. 
  
  
  Regards,
  
  *** ******

• Initial Complaint

  04/14/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  My mother ***** **** has been receiving Wavier Services since June 25th 2019.. I went through an agency called, *********** ********** *****r located in Harrisburg, Pa.. The person who is working taking care of my mother never recieved any payments..I wasn’t aware of the fact that she was still receiving Wavier Services until I called IEB and wanted to find out if I could reapply? The woman told me to call her insurance provider and speak to the supervisor and let them know that het care provider is to get paid retroactive from the time she was approved for wavier services and if I don’t get satisfaction then to call or write to the Complaint and Grecance Department. I tried numerous times with UPMC staff and I could not get any help or support at all… The first time I asked to speak to the supervisor the lady connected me to Independentl Enrollment Broker.. I had the phone number changed a few times and I wrote and called to make sure they got it so they would call and let us know what’s going on? Nobody ever came to the house and checked on my mother nor wrote a letter when they claim they tried calling but they claim they couldn’t reach anyone.. The reason for them not being able to reach anyone is because they was failing the wrong phone number… The woman had and has me and my care giver very stressed and emotionally upset.. The women was very rude and she kepted arguing with me as if they was in the right… I did everything I was suppose to do to have my mother recieve care and it took a while to have everything done.. I’m lost for words and I’m very upset because they aren’t doing their job correctly and it isn’t fair that the care taker hasn’t received payments..?My mother only allows either me or ******** taking care of her..That is her right.. My mother has Dementia and it’s progressed.. The care taker has mentioned that he needs help retrieving what’s owed to him… Her memory is not good ..? She needs to be supervised for safety reasons…(max hours )

  Business response

  04/25/2022

  UPMC Health Plan, Inc. ("UPMCHP') has received and reviewed your letter dated April 14, 2022 as well as the accompanying complaint. 
  Because the complaint did not include a HIPAA-compliant authorization that would permit UPMCHP to disclose any protected health information to the Better Business Bureau, we are unable to provide you a detailed response regarding the complaint. However, we will determine whether the affected individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to them regarding the stated concerns. 
  Thank you for bringing this matter to our attention. Should you have any questions or concerns, please do not hesitate to contact me at (**** ********* 
  Thank you. 
  

  
  

• Initial Complaint

  04/12/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  Paid my monthly bills that apparently went to a different Upmc address. Subsequently found out when I went to get a prescription filled that my policy was cancelled. Never got notification or any warnings. When I called to infer, they told me that I did not pay my premium so I was cancelled. When I offered to provide them proof that I paid, they would not accept and the person I spoke with on April 11, essentially said I was lying. When we finally figured out that payment was sent to the wrong address, I was told they would get the situation resolved and promised me a phone call the next day with the resolution. They also told me they needed to contact billing, which was not open at the time I called. However, it was open the following day at the same time when I called, the rep was able to call billing. Nonetheless, never got a call the next day as promised and had to call myself where I was told that the person I spoke with the day before, completely misinformed me and that the resolution could not be solved for at least one week. In the meantime, I’m not only without insurance right now (which I paid for), but when they resolve it a week from now, I’m going to not get refunded the time I was without coverage. So in essence, they are keeping my money. They told me that this is because of the affordable care act. I’m not even registered in that act because I pay full coverage. All I know, is while they are figuring this out, I have no health coverage and they are doing zero to rectify quickly. If I get Ill, I am not covered and could lose everything if I end up in the hospital. All Upmc health plan cares about is the payment that went to the wrong place and there is nothing they can do right away. Is this a good way to treat members especially one who is a physician. Even after I told them I was a physician, they continued to call me mister which I feel is disrespectful from a health insurance customer support supervisor. I am willing to supply proof of my

  Business response

  04/25/2022

  UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated April 13, 2022 as
  well as the accompanying complaint.
  Because the complaint did not include a HIPAA-compliant authorization that would permit UPMCHP to
  disclose the protected health information to the Better Business Bureau, we are unable to provide you a
  detailed response regarding the complaint. However, we will determine whether the affected individual
  is a UPMCHP member and, if so, will respond directly to them with a more detailed response.
  Thank you for bringing this matter to our attention. Should you have any questions or concerns, please
  do not hesitate to contact me at ***** *********
  Thank you.

  Customer response

  04/25/2022

  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.
  
  

  
  

  I was told the money that I was supposed to have refunded was supposed to be mailed. I then called and was told that the money is still not mailed and it will be mailed soon. I should receive a receipt via email which I never got. So obviously the money will never make it to my house that I have owed to me. Not sure what other recourse I have since UPMC does not care to refund my money in a timely manner. However if I owe them money like I did, they would be all over me to pay. 
  

• Initial Complaint

  04/01/2022

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Answered

  More info

  I am insured through UPMC for Life HMO Medicare Advantage Plan. I will receive a small bill once in a while with no itemized breakdown nor explanation what the charge is for, or what service was provided. Today I had a $10 charge with no explanation on my online dashboard. I ‘d recently went to my PCP for a 6 month checkup. UPMC has been caught overcharging before, and has settled. Claiming to vigorously defend other lawsuits on overbooking is sort of an admission of guilt IMO. These results are retell published u less a class action suite or a slow news day. I also will receive an unsolicited call once in a blue moon on a Wednesday to attend an online seminar. Voluntary of course. I did complain to the BBB about this in the past, I want no calls from UPMC. I did receive a letter from one of their attorneys about this. My SIL was an ABA executive a few years back, and lawyers do not have the best reputation there……. I want an explanation of why I suddenly owed $10 with. I explanation. I want this refunded if I did. Ot actually owe this amount. I miss having SCAN Medicare coverage out west. Never had any billing issues.

  Business response

  04/18/2022

  This complaint was referred to the UPMC Health Plan for their review on 4/12/22. They will review billing complaint and also provide Mr. ****** with an "opt out" for receiving any further correspondences/calls from UPMC that are not directly related to his care/billing.

• Initial Complaint

  02/25/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  I have UPMC For You (ID***********) health insurance and the dental plan that goes with it. I went to the *********** ****** ******* ** ******* **** ************ ** ****** on 4/19/21 and saw Dr. ******. He informed that I need 3 root canals and need to see an Endodontist for teeth 24,25, &26. They don't do them there and told me I had to take my referral paper to another facility to get the root canals done. I then contacted **** ****** ****** ******** in Port Allegany, PA ************** and they couldn't get me in until December 13th, 2021 for an appointment. Quite the wait. I finally got in there and saw Dr. ********** and he confirmed what the Johnsonburg dentist said and that he also could do 1 of the 3 root canals and I would have to go elsewhere. I called my insurance that same day and asked for help with this issue and the closest place that takes my dental insurance is 170 miles away! I stated that was unacceptable and I have been looking for help with my teeth since April. He assured he would "mark the ticket as high importance" and get back to me within 48 hours. 2 weeks later I still had not received a call so I called again and explained the situation. I was once again assured the SAME results. Once again that did not happen and I had to call back AGAIN. For the 3rd time I was assured they would find me help and a closer Endodontist even if it were out of network....Still has not happened. I phoned UPMC for a 4th time today, 2/10/22, and spoke with ********. I explained the whole situation again and she made a couple of phone calls to places that should take my insurance claiming a place in ****** ** accepts it- Dr. ******* *************). I went to make that appointment and they said they to contact their sister office in ******** ** because they no longer have the equipment to do root canals. I called the Delevan office and they said they do not accept my insurance. I have been lead in circles for almost an entire year now to get my teeth tended to.

  Business response

  03/23/2022

  The following constitutes UPMC Health Plan's (UPMCHP) response to a complaint filed by ******** ***** at the above-captioned file number.

  Ms. ***** complains that she has been unable to locate a dental provider and been unable to have her teeth tended to, she is requesting adequate dental treatment be provided either in- or out-of-network by her insurance company, UPMCHP. 

  Ms. ***** was a member of UPMC for You (UPMCFY), a Medical Assistance managed care product, since November 15, 2017. According to Ms. *****' complaint, she went to *********** ****** ****** in April 2021 and saw Dr. ******, who advised she needed 3 root canals and to see an endodontist - services which are not performed at that office. Ms. ***** states she contacted **** ****** ****** ********, which did not have an appointment until December 13, 2021. On that date, she saw Dr. ********** who confirmed what Dr. ****** advised and stated he could perform 1 of the 3 root canals but she would also need to be seen elsewhere. Ms. ***** states she telephoned UPMCHP that day and requested assistance, she was allegedly told the closest dental location which accepts her insurance was 170 miles away but was assured she would receive a response within 48 hours. Ms. ***** allegedly telephoned UPMCHP on two subsequent occasions without receiving a response. During a later call to UPMCHP, Ms. ***** states she was told she would receive assistance with finding an out-of-network endodontist but that has not occurred. Ms. ***** alleges she was later advised by UPMCHP that Dr. ******* in Olean, NY would accept her insurance, but later discovered his office does not have the equipment to perform root canals and his sister office does not accept UPMCFY. 

  According to UPMCHP records, Ms. ***** telephoned UPMCFY Member Services on February 18, 2021 and was provided information regarding Olean General Dentistry. She telephoned again on March 10, 2021 and was given the names of a several in-network providers. On June 17, 2021, Ms. ***** telephoned for further help with dental concerns and was given another provider option. On December 13, 2021, she telephoned and was advised of Casey Dental. On January 11, 2022, Ms. ***** telephoned Member Services checking on her request, and the Member Services representative followed up with SkyGen, which is UPMCFY's dental administrator. Ms. ***** telephoned again on January 25, 2022 and was advised a ticket with Azure had been submitted to SkyGen. She called UPMCFY Member Services on February 10, 2022 and was advised of the out-of-network authorization process, additionally, the Member Services representative assisted in locating out-of-network options for Ms. ***** but, unfortunately, none of the out-of-network providers contacted were willing and/or able to performed the procedures she requested. 

  UPMCHP has performed a provider search and, unfortunately, there are no in-network endodontists within 100 miles of Ms. *****' home address. There are numerous general dentistry practices within that radius. When there are no in-network options for a member within a certain distance from the member's home address, the member should contact Member Services to inquire about filing an out-of-network request. According to UPMCHP records, Ms. ***** was advised of this process on February 10, 2022. 

  Additionally, UPMCHP benefit documents indicate that root canals are not a covered under the UPMCFY plan for members over 21 years of age without an approved Benefit Limit Exception (BLE), which requires certain criteria to be met before approval. According to the UPMCHP records, there have been no prior authorization requests submitted by any provider for Ms. *****. 
  
  Finally, it should be noted that Ms. ***** has not filed any complaints or grievances with UPMCFY. 

  Thank you for bringing this matter to our attention and allowing the opportunity to provide a response. If you have any questions or concerns, please do not hesitate to contact me at (**** ********* 
  

  
  

• Initial Complaint

  02/23/2022

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  They are constantly mailing me advertisements & flyers, monthly, if not more! I have called them, every time I receive them, asking them to stop mailing me information or flyers, that I’m not interested. The person on the other end says there’s a notation on their computers, not to mail me or contact me anymore, but each month or more, they keep mailing me! I’m feeling harassed by UPMC for Life.

  Business response

  03/08/2022

  UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated February 23, 2022
  regarding Mr. *****’s receipt of marketing material from UPMCHP related to its Medicare Advantage
  product. Specifically, Mr. ***** complains that he has been receiving unsolicited mail from UPMC for
  Life despite having notified UPMCHP that he is not interested in obtaining coverage through UPMC for
  Life.
  Upon investigation of this matter, UPMCHP has determined that materials sent to Mr. ***** were
  marketing-related. UPMCHP understands the frustration this situation has caused and has taken
  appropriate steps to remove Mr. ***** and his corresponding home address from UPMC for Life’s
  marketing database. Please note that we supply mailing lists to our marketing vendors several weeks in
  advance, so Mr. ***** may receive additional marketing materials after receipt of this correspondence.
  UPMCHP regrets any inconvenience to Mr. ***** and thanks the Bureau for bringing this matter to our
  attention.
  Thank you.

*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. ↩