Complaints

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:03/25/2025

  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 am unsure where to start but, in the interest of space, initially claims for my therapist were denied citing an incorrect "out of network" error (was actually a data entry error on UPMCs part) for months. After arguments for months and needing to resort to an ultimatum: that my claims be processed or I involve the state, they were paid - and quickly. This month (just over the last 2 weeks) my psych-med provider submitted a prescription that was not filled due to needing a prior authorization. She completed the authorization. The medication was still denied, citing **** needed EXTENSIVE documentation that multiple other medications and combinations of medications had been tried. My current provider does not have access to all previous records due to a fire and to the closure of a previous practice.I have needed a prior authorization for a physical health condition (non-emergent) and it was approved with almost no push back. Nearly every mental health service or medication request is met with resistance. Obvious discrimination and/or retaliation for the push for previous claims to be paid. **** has paid for my adhd medication (controlled substance) and antibiotics and migraine meds (phys health meds) but a med that could save my life, lessen depression, and be potentially life-saving they won't cover without excessive hoop-jumping or requirements to try meds that my medical provider and I feel are not in my best interest? (Have tried most) Picture attached shows upmc's picture of "upmc's anatomy" that places mental health at the top. Other picture is all requirements that must be met with documents. note: med is for an antidepressant, not a controlled substance.

  Business Response

  Date: 03/31/2025

  See attached.

  Customer Answer

  Date: 04/02/2025

  See attached.

  Business Response

  Date: 04/04/2025

  Dear *** ******: 

  UPMC Health Plan****** (UPMCHP") has received and reviewed your letter dated March 25, 2025 as well as the Authorization to Release Health Information signed by ******* ******* on April 2, 2025. Please accept the following as ******'s response to your letter and the accompanying complaint filed by *** *******. 

  *** ********* complaint stems from a prior authorization request for the prescription medication, AUVELITY ER ****** MG TABLET (AUVELITY). According to our records, *** ******* is enrolled in a **** ******************************* (EPO) plan, a fully insured group health plan sponsored by her employer and offered by UPMC Health Options, Inc. 

  A prior authorization ("PA") is the process through which UPMCHP determines whether certain treatments or services are medically necessary and that such treatments or services will be obtained in the appropriate setting. For some medications, a provider must submit a PA request to ******'s **************************** before prescribing the medication.1 ***************** must authorize a member's use of the medication in order for it to be covered. As listed in the 2025 Your Choice formulary, the medication AUVELITY requires a PA.2
  
  According to ****** records, *** ********* provider, ***** *****, submitted a PA request for *** ******* to receive coverage for AUVELITY on March 20, 2025. ************************ reviewed and denied this PA request on March 22, 2025. The PA request did not include the documentation required to demonstrate that *** ******* tried other medications prior to requesting a PA for AUVELITY. Specifically, the documentation did not support that *** ******* tried the following: 

  (1) a trial of at least 4 weeks with each of the following: (a) four generic antidepressants (such as drugs from the **** or SNRI drug classes); (b) either ********** or ******* (both require prior authorization); (c) one generic **** or SNRI antidepressant in combination with bupropion; and (d) two different augmenting therapies (such as buspirone, antipsychotics, or tricyclic antidepressant) in combination with an **** or SNRI antidepressant. Chart documentation of the medication trials is required. 

  *** ******* stated in her complaint that her current provider does not have access to her previous medical records. Additionally, *** ******* contacted ****** *************** to explain why her previous medical records are difficult to obtain. As such, ****** subsequently outreached to *** ********* provider to discuss the required documentation for the PA. *** ********* provider informed ****** that she would send a letter containing information regarding *** ********* medication treatment history. 

  Footnote 1   Prescription Schedule of Benefits, page 7. 
  Footnote 2   2025 Your Choice Pharmacy Benefit Guide, page 27 (excerpts attached). 
  

   

  Additionally, *** ******* filed a first-level appeal with UPMCHP on March 25, ********************************* ******* will receive a decision regarding this appeal within 15 days of the date on which the appeal was received. 
  

  As stated above, a PA is required for certain medications prior to receiving care. The medication AUVELITY requires a PA before UPMCHP will cover the medication. The PA request submitted by *** ********* provider for ******** denied because it did not meet the criteria for coverage. If *** ********* provider submits additional documentation, ****** will review the PA request for AUVELITY to determine if coverage criteria is met. 
  

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

  Respectfully Submitted, 
  

  ****** ******, Esquire 
  Staff Attorney 
  

  
  

  Customer Answer

  Date: 04/04/2025

  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.
  

  
  ADDITIONAL INFORMATION:

  I usually only speak to representative of UPMC via chat or message due to this type of
  situation (unable to have exact words of what I was told in conversations).

  In past conversations I was told many differing accounts of what could or should happen
  and issues were not resolved until I researched them independently and called out the
  inconsistencies. All mental health related.

  In this situation, and all calls are recorded, I urge you to pull the recorded call with the
  representative in this chat (who, by the way is amazing so there is no personal
  animosity), I was told if my provider called in and explained that I have tried several
  meditations but the records situation is complicated and most are unavailable, the
  medication would most likely be able to get authorized.

  In addition, medications on the list that were not attempted were not tried for medical
  reasons.

  A member should not have to be subjected to adverse effects to prove another
  medication is necessary. Which should go without saying as it would end up costing the
  health plan more money.

  If my claims are reviewed, it will be clear to see that past prior authorizations that are
  solely related to physical health concerns were approved without much pushback. Many
  even standard claims claims were denied or made difficult pertaining to mental health
  issues.

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

  Business Response

  Date: 04/08/2025

  UPMC Health Plan****** ("UPMCHP") has received the additional information submitted by ******* ******* on
  April 4, 2025, as well as the Authorization to Release Health Information signed by Ms. ******* on April 2, 2025.
  Please accept the following as ******'s supplemental response to the additional information.

  After review of the additional information submitted by Ms. ******** ******'s previous response submitted
  on April 3, 2025 remains unchanged. As stated in ******'s prior response, Ms. ******* contacted ******
  Member Services to explain why her previous medical records are difficult to obtain. As such, ******
  subsequently outreached to Ms. ********* provider to discuss the required documentation for the prior
  authorization. Ms. ********* provider informed ****** that she would send a letter containing information
  regarding Ms. ********* medication treatment history. If Ms. ********* provider submits additional
  documentation, ****** will review the prior authorization request for AUVELITY ER ****** MG TABLET
  to determine if coverage criteria is met.

  Thank you for bringing Ms. ********* additional information to our attention. Should you have any further
  questions, please contact our office.
  

  Customer Answer

  Date: 04/08/2025

  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.
  
  It is clear that the "business" is not interested in resolution or actual patient care. They were explained why they could not be given detailed records and prescriber attested to previous attempts at medication trials. 

  Records that are unavailable are...unavailable.  If records were lost in a fire or are in possession of a business that no longer exists...they no longer exist. 

  UPMC uses the same prescription service (ExpressScripts), as I told them during our initial chat and call, and I am sure they could send a release to get previous meds used from a longer time period than is available to me from that service. 

  They have not. 

  Or they could just act in the best interest of their members but, that's rarely the case.

  If they need documentation, they could get documentation that is not available to me (only ***** months is available to me) from a service they are affiliated with - they seem to have releases for everything else. 
  
  Regards,
  
  ******* *******

  Business Response

  Date: 04/09/2025

  UPMC Health Plan****** ("UPMCHP") has received the additional information submitted by ******* ******* on April 8, 2025, as well as the Authorization to Release Health Information signed by Ms. ******* on April 2, 2025. Please accept the following as ******'s supplemental response to the additional information. 

  After review of the additional information submitted by Ms. ******** ******'s previous response submitted on April 3, 2025 remains unchanged. As stated in ******'s prior response, UPMCHP outreached to Ms. ********* provider to discuss the required documentation for the prior authorization. Ms. ********* provider informed ****** that she would send a letter containing information regarding Ms. ********* medication treatment history. If Ms. ********* provider submits additional documentation, ****** will review the prior authorization request for AUVELITY ER ****** MG TABLET to determine if coverage criteria is met.

  If Ms. ******* has any additional questions or concerns, she may contact ****** *************** at the phone number located on her Member ID card. 

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

  Respectfully Submitted, 
  

  ****** ******, Esquire 
  Staff Attorney 
  

  
  

  Customer Answer

  Date: 04/14/2025

  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.
  
  The business continues to post the same policy about records I have repeatedly told them are unavailable.  

  They continue to tell me to contact member services when they assured me informing upmc of the records situation would help with the authorization but it has not. 

  It seems they are using the records being unavailable as a means to withhold medication even though myself and my provider have attested to the qty of other options tried. 

  I understand the importance of policy. I also understand discrimination and bias. 

  And I received my denial in the mail today...it was denied my an emergency medical physician- someone much less qualified than my psych-med provider.  

  INSULTING. 

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

• Initial Complaint

  Date:03/01/2025

  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 set up an HSA at the beginning of 2025. **** has been nonexistant in the setup process. They never sent me a debit card until I called and asked them. Then, they finally sent the debit card but there is no instructions on how to fund it. I poked around on their cryptic UPMC Consumer Advantage website and found an instruction manual. However, the instructions contained in the manual do not mirror what is on the website, which renders them useless. They routinely state they have support available on Saturday but after calling the numbers listed, I found out that discriminate against people like myself that have an individual plan and they only provide weekend support for UPMC for Life and UPMC Health Group Plan. This is terrible. Lastly, I tried their useless chatbot that provided a link to funding my HSA but of course the link doesn't allow you to do what you are supposed to be able to do. Long story short...we are now into the third month of the plan year and we still have not been able to use the plan as it was intended, yet they take my health premium of $406 every month. ****, along with Highmark, are two of the worst healthcare providers in the region...not surprising, though. When you allow the market to be monopolized by two entities, this is the result that is expected. I am also filing a complaint with the PA insurance **********

  Business Response

  Date: 03/11/2025

  See attached.

  Customer Answer

  Date: 03/17/2025

  See attached.

  Business Response

  Date: 04/09/2025

  UPMC Health Plan****** ("UPMCHP") has received and reviewed your letter dated March 3, 2025, as well as the Authorization to Release Health Information signed by ***** **** dated March 16, 2025. Mr. ****** complaint lists difficulties he has faced in opening and contributing to a Health Savings Account (HSA), 
  

  ******'s enrollment records indicate that since January 1, 2025, Mr. **** has been enrolled in a **** ************************************************ (EPO) plan that he purchased from UPMC Health ************* (NAIC No. 15345). 
  

  Mr. ****** plan is a qualified high deductible health plan, which means that he may open and contribute to an HSA if he meets other IRS criteria.1 An HSA is a tax-exempt trust or custodial account that a person sets up with a qualified HSA trustee to pay or reimburse certain medical expenses. The *** can be established through a trustee that is different from one's health plan provider.2 To set up an HSA, Mr. **** may contact the HSA administrator of his choice or contact *******3 For the convenience of its members, ****** has partnered with an affiliate, ************************************** ("UPMCBMS), which administers **** Consumer Advantage, an *** account service. While the **** ************************** is affiliated with ****, it is administered separately from the health benefits offered by UPMC Health Plan. 
  

  According to our records, on February 10, 2025, Mr. **** contacted ****** member services requesting to open an *** with **** Consumer Advantage. ****** member services referred the request to *******, and ******* opened a UPMC Consumer Advantage HSA account for Mr. ***** On February 13, 2025, UPMCBMS sent him a **** Consumer Advantage debit card by mail to his address on file. 
  

  On Saturday, March 1, 2025, Mr. **** called ****** member services requesting to speak with a **** Consumer Advantage representative regarding his HSA. Mr. **** did not provide specifics to his concern. ****** member services advised him that **** Consumer Advantage customer service representatives were not available on weekends. At Mr. ****** request, ****** member services helped him leave a message for **** Consumer Advantage's customer service to call him back. 
  

  According to information from UPMCBMS, as of March 7, 2025, Mr. **** had successfully opened and contributed to his HSA. 
  

  Footnote 1 Schedule of Benefits, 1 (attached). 
  Footnote 2 IRS Publication 969, at 3 (excerpt attached). 
  Footnote 3 Schedule of Benefits, 1 (attached). 
  

  Mr. **** may manage his UPMC Consumer Advantage HSA account 24/7 by accessing his secure online account or via the mobile app. In addition, **** Consumer Advantage customer service representatives are available at ************** Monday through Friday, 8 a.m. to 6 p.m. 
  

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

  Respectfully Submitted, 
  

  "*******" ******** **, Esq. 
  Staff Attorney 

  Customer Answer

  Date: 04/10/2025

  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.
  
  Regrettably, the junior attorney's severely delayed letter does not rise to the level of a response. I will address my questions again in a very succent manner to refocus the junior attorney. I am a *** licensed to practice in this Commonwealth so I do not require, nor did I ask for, an analysis of tax law as it relates to ***. 
  
  1. The junior attorney indicates that the member MAY open and contribute to an ***. Interestingly, **** own website states that an *** is included with all HDHP.*******************************************************. To suggest that someone would enroll in a plan with ridiculously high deductibles and NOT take advantage of the *** defies logic.
  2. I stated that once I received the debit card, there were no instructions provided and the website on the Consumer Advantage website contained incomplete, inaccurate and erroneous information. The junior attorney did not respond to this fact.
  3. I stated that phone support was not made available to me on Saturday despite the voicemail system indicating it was and despite **** providing phone support to members of other health plans. Again, the junior attorney did not respond to this fact.
  4. The junior attorney attorney stated I called **** on March 1 and did not state the reason for my call. This is an outright lie and frankly defies logic. I am not sure how that conversation would go...**** may I help you....my response...silence?
  5. On  March 7, I opened my *** and contributed to it. Yes, we agree.
  
  This response is rejected outright and is now referred to and is being handled by the ************************
  The BBB case may be closed as unresolved. If you consider the severely deayed letter from **** to be a response, then say the business responded. It does not rise to the level of a response and is intended to distract from the issues raised in my complaint.
  

  Regards,
  
  ***** ****

   

  Business Response

  Date: 04/15/2025

  UPMC Health Plan****** ("UPMCHP") has received your correspondence dated April 10, 2025, regarding *** ***** ****** dissatisfaction towards ******'s April 8 response to his complaint. 
  

  *** **** expressed his dissatisfaction with the promptness of UPMCHP's response. The original letter from your office dated March 3, 2025 did not include a HIPAA authorization from *** **** that would allow UPMCHP to disclose his protected health information. In our March 10 response, we explained that without a HIPAA- compliant authorization, UPMCHP was unable to provide a response to the Better Business Bureau regarding ************** complaint. After we received the required ***** authorization, ****** provided a response to the Bureau regarding *** ****** complaint. ****** follows careful procedures to ensure that disclosures of members' protected health information are compliant with HIPAA. We apologize for the delay and for the frustration experienced by *** ****. 
  

  With respect to the additional items listed in *** ****** April 10 correspondence, we respectfully note that the website *** **** cited is specific to Federal Employee Health Benefit plans. *** **** was not enrolled in a Federal Employee Health Benefit plan, and therefore the information on the website he cited is not applicable to him. 
  We also acknowledge *** ****** dissatisfaction with his customer service experience. We respectfully note again that Health *************** services are provided by **** Consumer Advantage, which has different customer service hours than **********************. 
  

  We apologize for any inconvenience to *** **** and thank the Bureau for bringing this matter to our attention. We believe that our previous responses have sufficiently addressed *** ****** concerns regarding UPMCBMS's customer service. If *** **** needs further assistance with his HSA, we ask that *** **** please contact **** Consumer Advantage customer services. 
  

   

  Customer Answer

  Date: 04/16/2025

  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.
  

  
  We just deal with facts here. My records show that the unnecessary hipaa authorization was provided to **** on or around march 17. The junior attorney then proceeded to take over 21 days to draft an amateur response that failed to address many specific issues. She cited tax law and all kinds of legal jargon, none of which required hipaa pre authorization. The attempt to blame hipaa for their delays fails miserably.

  The entire purposes of purchasing a hdhp is to link it with an hsa. She continually fails to acknowledge this. Regardless of whether it is a student plan, employer offered plan, government plan or marketplace plan, no one, I repeat no one, would enroll in a hdhp and not link it to an hsa. The upmc health plan, and its wholly owned affiliate **** consumer advantage, failed to offer these basic services and required the member to jump through all kinds of hoops and incur unreasonable time delays. The website contained and still contains inaccurate, incomplete and erroneous information. I purchase my health insurance through upmc health plan. I also make outrageous monthly premium payments to ****. To this end, the health plan remains directly accountable to its paying members. Attempts to ****** this responsibility to other operating entities fails miserably. At this time, the matter with bbb should be closed as unresolved. I have electing to forward this to the ********************************* consumer protections unit and they will handle the matter from here.

  
  
  Regards,
  
  ***** ****

• Initial Complaint

  Date:02/25/2025

  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.

  I am filing this complaint against UPMC Health Plan due to an unjust denial of my emergency medical claim, repeated misrepresentation of my benefits, and an unreasonable delay in processing my dispute.On September 11, 2024, while traveling in *******, ********, I suffered a medical emergency and was taken to ************* Emergency Room. I was then admitted to the hospital for continued treatment. My insurance plan with **** clearly states that emergency services are covered, and the ** copay is waived if the patient is admitted.However, despite following all necessary procedures and submitting my claim in October 2024, **** wrongfully denied my reimbursement of $3,591.34 based on the following:- UPMC incorrectly claims my hospital admission was not classified as an ** admission, despite clear evidence that I was admitted directly from the **.- They denied room charges, despite the fact that a hospital stay requires a room, and this is a standard billing practice in *********- The claim was denied under "Authorization for Services Not on File", even though emergency care does not require prior authorization under my policy.- I was explicitly told by **** representatives that my emergency admission should be covered, yet they continue to deny the claim.- Additionally, **** has failed to adhere to its own 40-day dispute resolution policy. I submitted my dispute months ago, yet every time I call, I am told that it is still in processing. I have spent hours on the phone, being transferred between departments with no resolution. Meanwhile, I am expected to pay my premiums and medical bills on time, while **** is failing to fulfill its obligations.Resolution Requested - Immediate reimbursement of $3,591.34 (paid at the time of service), per my insurance coverage.- A formal explanation for the improper classification of my admission and denial of hospital stay charges.- Accountability for the excessive delay in claim processing.

  Business Response

  Date: 03/07/2025

  See attached.

• Initial Complaint

  Date:02/20/2025

  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.

  My complaint is about the reward incentive program. On February 4th 2025 I had my annual Mammogram which I am supposed to get $50.00. I have yet to receive it and the claim was processed February 10th. I have called three times the third time I asked to speak to a supervisor. Every time I call I get told that the reward program doesn't start paying rewards until the end of the 1st quarter which would be April. I don't think this is true because I have gotten rewards in February before, but if it is true I think they should let people know this. I can't find any information on when they pay rewards.

  Business Response

  Date: 02/26/2025

  
  UPMC Health Plan****** ("UPMCHP") has received and reviewed your letter dated February 20, 2025 as well as the accompanying complaint. 
  

  The above-referenced complaint did not include a HIPAA authorization that would allow ****** 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, 
  

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

  Business Response

  Date: 03/03/2025

  UPMC Health Plan****** (******) has received and reviewed your letter dated February 20, 2025 as well as the accompanying complaint.The above-referenced complaint did not include a HIPAA authorization that would allow ****** 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, ****** 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.

• Initial Complaint

  Date:01/03/2025

  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.

  I have vision benefits through upmc for life policy.my benefits give me $200 towards frames it pays for eye exam and lenses. I got different type of lense that according to my explanation of benefits was and additional $60 charge.also looking at (eob) my frames where $240 so that would be an additional $40. According to (eob) I should of been charged $60 for upgrade on lenses and $40 for frames totaling $100 total to pay to my eye dr. My eye doctor charged me $230 and i paid it. Ive contacted upmc 5 times to verify to my eye dr that charge should of been $100 instead of $230. To no avail upmc cant seem to verify to my eye dr. That accordjng to there own (eob) i should of been charged $100 instead of the$230 . Ive been hung up on referred to 3 different people with no resolution to problem .just being told there working on it. Its either covered or not dont understand what there working on.I spoke to vendor (my eye dr) and there waiting for upmc to answer them.I pay for upmc insurance thsts who im dealing with not vendor or there 3rd party nv vision company and they cant give me any explanation so i can get.my refund for overchage.

  Business Response

  Date: 01/15/2025

  
  UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated January 3, 2025 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 ("BBB") 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. 
  

  If a HIPPA-compliant authorization is provided, UPMCHP respectfully requests a short extension in order to fully address the matters detailed in the complaint in a written response to the BBB. 
  

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

  Respectfully Submitted, 
  

  Ashton H*****, Esquire 
  Staff Attorney 
  

  
  

   

• Initial Complaint

  Date:01/02/2025

  Type:Sales and Advertising 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.

  **** offered a $15.gas card at ****** for looking at their information, which I did... I finally did switch to **** from Aetna, and I'm very sorry that I did... I contacted **** on this missing ****** gas card on 9/22/24....10/14/24..12/9/24..I talked to **** ******, and today twice they hung up on me.!!!. They owe me a $15 ****** gift card. They've made this offer to 2 of my friends and my sister in law and never follow thru with offer... They need to be held accountable...

  Customer Answer

  Date: 01/06/2025

  See attachments.

  Business Response

  Date: 01/13/2025

  Dear *** ******: 

  UPMC for Life (UPMCFL) has received and reviewed your letter dated January 2, 2025 as well as the Authorization to Release Health Information signed by ****** **** Please accept the following as ******'s response to your letter and the accompanying complaint filed by *** **** 
  

  *** ***** complaint stems from issues with receipt of a complimentary gift card. According to our records. *** *** is enrolled in a UPMC for Life **************************************************** plan. 
  

  As noted in *** ***** complaint, she received a flyer from ****** offering a complimentary $15 gas gift card for requesting information about certain ****** plans. *** *** also stated in her complaint that she contacted ****** on various occasions to inquire about the status of her gift card. Upon review by ******, we were unable to locate any calls from *** *** to UPMCFL related to the gift card. 
  

  However, in efforts to resolve *** ***** complaint, ****** will mail a $15 gas gift card to *** **** The gift card may take up to ten business days to be delivered. 
  

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

  Respectfully Submitted, 
  

  ****** ******, Esquire 
  

  Staff Attorney

  UPMC Health Plan 
  

  
  

  
  

  Customer Answer

  Date: 01/13/2025

  
  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:12/05/2024

  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.

  I have my UPMC Health Insurance on auto pay. However, they said they haven't billed the last two months because they didn't have my updated Credit Card Expiration Date because unlike the majority of merchants do not have the API to get this information. They said they sent out notices in the mail, but I did not receive them. Instead, when I log into my ****** account I see that my insurance is still active and that I received my card for the following year. Now I can't get my life-saving medication because they terminated coverage. I have tried speaking to a supervisor and they said they can't undo what they have done in the system and that they are okay if I die.

  Business Response

  Date: 12/13/2024

  UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated December 5, 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.

• Initial Complaint

  Date:11/05/2024

  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.

  **** refuses to cover an antiobesity agent though I meet all required prescribing criteria. I pay a lot for my copays and insurance and I am disgusted that **** would rather pay for invasive bariatric surgery than approve a temporary prescription.

  Business Response

  Date: 12/04/2024

  UPMC Health Plan (****HP) has received and reviewed your letter dated November 5, 2024, as well as the
  Authorization to Release Health Information signed by ****** *******. Please accept the following as ****HPs
  response to your letter and the accompanying complaint filed by Ms. ****************** ******** complaint stems from issues with ****HPs denial of a prior authorization for Wegovy 0.25
  MG/0.5 ML Pen. According to our records, Ms. ******* is enrolled in the **** ****************** Provider
  Organization (EPO) Premium Network plan for the 2024 benefit year.

  Under certain circumstances, prescription drugs and medical services that may otherwise be covered are excluded
  from coverage under a members benefit plan. These circumstances are known as exclusions and are detailed in
  the members Certificate of Coverage (***), which is the contract between the member and ******. One
  such exclusion includes drugs and services provided to treat weight reduction. The *** states specifically under
  exclusion 39 regarding weight reduction:

  Weight reduction programs not included in the ******************* Reference Guide. Weight
  reduction programs, including all related diagnostic testing and other services, except when such
  coverage is required by the *************** Act. Anti-obesity medication, including, but not limited
  to, appetite suppressants and ****** inhibitors unless you have coverage for anti-obesity
  medications in your Prescription Medication Schedule of Benefits. 1

  According to our records, Ms. ******** provider, ***** *******, submitted a Prior Authorization Form for the
  medication Wegovy 0.25 MG/0.5ML Pen to treat the diagnosis of obesity on November 5, 2024. ****** denied
  the request on November 5, 2024, because drugs used for weight loss are not a covered benefit, as noted above in
  Ms. ******** ***.

  If Ms. ******* is dissatisfied with the denial, she may exercise her internal appeal rights with ******. As detailed
  in the ***, Ms. ******* may file an appeal within 180 days of the date on which the denial occurred.2 She may
  call the *************** phone number on her member ID card to file an appeal.

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

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

   

  1 See 2024 Certificate of Coverage, page 30.

  2 See 2024 Certificate of Coverage, Resolving Disputes with UPMC Health Plan.
  

   

   

  Customer Answer

  Date: 12/05/2024

  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 already tried appealing this last time we tried to get this approved. 
  
  Regards,
  
  ****** *******

• Initial Complaint

  Date:09/27/2024

  Type:Service or Repair 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 for years now in past received mailings from UPMC For Life for **** *****, my sister-in-law who passed away about 2-3 years ago. Also, for the past year, I have received mail from UPMC For Life ******* *****, my mother who passed away 11/2023. I have written the firm and have called and talked to the firm by phone and in past month when speaking to *** I was told this would be taken care of, but it has not since I just got a letter for my mom about a week or so ago. The mailings come to ***************************************** which is both of theirs last known residence and now my residence. I tried a couple of ways to get this resolved but no matter what I have done the mailings continue for both of my deceased relatives. Please help me to get this firm to stop the mailings for these are two people who cannot receive this mail and I personally have no use for the mail, etc.

  Business Response

  Date: 10/08/2024

  UPMC Health Plan****** (UPMCHP) has received and reviewed your letter dated September 27, 2024, regarding 
  Mr. ***** ****** receipt of marketing material from ****** related to its ******** Advantage product. 
  Specifically, Mr. ***** complains he has been receiving unsolicited mail from UPMC for Life on behalf of his late 
  sister-in-law **** ***** and late mother ******* ***** despite having notified UPMCHP. 

  
  Upon investigation of this matter, ****** has determined that materials sent to Mr. ****** home were marketing 
  related. ****** understands the frustration this situation has caused and has taken appropriate steps to remove 
  Ms. **** *****, Ms. ******* *****, and their corresponding home address from UPMC for Lifes 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. 

  
  We apologize for any inconvenience to Mr. ***** and thanks the Bureau for bringing this matter to our attention. 
  Should you have any further questions, please contact me at ************. 

  
  Respectfully Submitted, 

  
  ******* Rongxuan **, Esq. 
  Staff Attorney 
  UPMC Health Plan

  Customer Answer

  Date: 10/08/2024

  
  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. I sincerely hope for resolve with this matter as of to date and, if not, I will be forced to continue filing complaints, if in due time, this issue with both my mother (*******) and Sister-In-Law (****) not receiving any mail directly or indirectly from this firm, are not resolved. 
  
  Regards,
  
  ***** *****

  Customer Answer

  Date: 10/28/2024

  I received a mailing from 'UPMC for Life' addressed to ******* ***** (my deceased mother) and filed a complaint to stop the practice, but it appears they will not stop. I also been receiving same mailings for ***** ***** (my deceased father) too. I have sent two faxes to the Corporate Attorney as well but no response to date. The Mailings need to stop and all I can do now is continue to file complaints since now not only my mother is still receiving the mailings but now my father as well.

  Customer Answer

  Date: 10/29/2024

  Please see attached.

  Business Response

  Date: 11/04/2024

  See attached.

  Customer Answer

  Date: 11/05/2024

  
  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 for the most part. If after a month (12/5/24) I am still receiving marketing mail with **** on it for either **** *****, ******* *****, or ***** *****, I will NOT call UPMC phone number **************** because they, I have found, are useless and besides I have contacted them in the past for these situations but despite them telling me it will be resolved, etc., the same problem(s) continued on occurring. I WILL continue to fax the ******************* for resolve since this seems to be the most effective way for resolving my concerns and issues in receiving any more mail addressed to my deceased family relatives. If **** office has a problem my circumventing the ******* via phone if the issues continue, then I ask them to place themselves in my shoes because I tried to do everything to cease the mailings to no avail. Please expect me to fax the ********** of **** in the future if I continue to get these mailings. Thank you.
  
  Regards,
  
  ***** *****

• Initial Complaint

  Date:09/17/2024

  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.

  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

  Date: 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