ComplaintsforCommunity First Health Plans

• Initial Complaint

  02/19/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Since November 2023, I have been waiting to see an ENT ******* ******* the network has only one ENT specialized in my issues, and He practices only two days a month, The Community first refused to authorize me to see an ENT outside the new work sooner, I am sick and getting worse I have received two denied letters from the community first

  Customer response

  04/01/2024

  Complaint: 21310129
  
  I am rejecting this response because: 

  Every time I ask appointment with ENT, it takes about 100 days waiting :

  1- My original referral was back November 2023,  My appointment set up was for 3/18/2024

  2- In march 18/24 I got a new referral TO New ENT, again I have to wait and my Appointment has been set up for July 22/2024

  I am sick , because My medical Insurance (The Community health plane) do not have enough ENT, so I have to wait a long time to see someone in the net work, My insurance not allowing me to go see some one outside the network.
  
  Regards,
  
  *******************************/18/2024

  Business response

  04/18/2024

  Re:  Compliant ID ********
  
  Thank you for your communication received on March 27, 2024, regarding the complaint ID listed above.  In response to your letter, a review of the members authorization and claims history was conducted.
  
  Community First Health Plans, **** (Community First) received original prior authorization request for an out of network ENT office visit from ******************************* on February 12, 2024. The prior authorization request was denied the same day as there was not an access issue.The member could have elected to see ******************************* using their PPO benefits which was also noted on the attached member denial letter.
  
  Community First attempted to work with the member and their primary care physician (PCP), **************, to get a referral with an in-network provider. On February 12, 2024, Community First contacted University Health ENT and they stated they were scheduling Nurse Practitioner appointments starting April to May at that time, and the member just needed a referral faxed over from PCP. Another call was placed to UT Health who stated they were currently scheduling starting as early as February 14, 2024. However,the member stated it would take too long to obtain an appointment.
  
  In November 2023, the member was setup with an ENT appointment with Dr. ************ on March 18, ************************** reviewing this members claim history, Claim No. 24087E03909 was paid to Dr. ************ was paid in the amount of $511.45 on March 28, 2024 for date of service March 18,2024.
  
  Please note Community First takes all complaints seriously. On April 14, 2024, Community First attempted to outreach to this member but was unsuccessful. Feel free to reach out to us with any additional questions at ***************************.  

  Customer response

  04/18/2024

  Complaint: 21310129
  
  I am rejecting this response because:

  1- Community first do not have enough ENT, It  is taking for ever,  for patinate,  to see a doctor. Just another example:

  One of the ENT I visited on March 28/ 2024 , He has referred me to another ENT, Now I have to wraith tile July 22,2024 another world I needed ENT from last November 

  2- Community fist refer  me to see a Urology, out side the network, but they denied to pay for my visit. Now I have received  a bill for  Urology (*********************) for $1654.93

  3- If community first health plane is honest:

  A) they will pay my Urology bill *************  **************************) The bill is attached.

  B) They won't force  me to wait tile July 22/24 to see and ENT in network. They authorized me to see out side network ENT, which they did not.

  C) Community first has mailed me the denied letter for seeing an Outside network ENT, they did not pay even PPO 
  
  Regards,
  
  *******************************

  Business response

  04/29/2024

  Good *************************************** **** (Community First) acknowledges receipt of the response below and note we take all complaints seriously and review accordingly.Community First does not have clinical documentation from the UT ENT visit on March 28, 2024 as no prior authorization is needed for In Network providers. Regarding the second referral to another ENT,Community First would need more clarification as to why ************************ was referred to another ENT. Please note Community Firsts ********************************* have made three unsuccessful outreach attempts to ************************ (Phone number #************). Several voice messages have been left for the member to call back so we may assist this member with no response. After the third unsuccessful contact attempt, Community First mailed the member an Unable to Reach letter on Tuesday April 23, 2024.
  
  Community First did not receive a prior authorization request for Urology with *************************** prior to visit. In turn, this resulted in denial of Claim No.23298E00309. Please note ************** was advised by Community Firsts ************************** on August 21, 2023 that a prior authorization is required prior to rendering services as ************** is Out of Network for ********************** Plan and First Health (PPO benefits).
  
  Feel free to reach out to me with any additional questions or concerns.
  
  I am rejecting this response because:
  1- Community first do not have enough ENT, It  is taking for ever,  for patinate,  to see a doctor. Just another example:
  One of the ENT I visited on March 28/ 2024 , He has referred me to another ENT, Now I have to wraith tile July 22,2024 another world I needed ENT from last November 
  2- Community fist refer  me to see a Urology, out side the network, but they denied to pay for my visit. Now I have received  a bill for  Urology (*********************) for $1654.93
  3- If community first health plane is honest:
  A) they will pay my Urology bill *************  **************************) The bill is attached.
  B) They won't force  me to wait tile July 22/24 to see and ENT in network. They authorized me to see out side network ENT, which they did not.
  C) Community first has mailed me the denied letter for seeing an Outside network ENT, they did not pay even PPO 
  
  Regards,
  
  *******************************
  

  Customer response

  04/29/2024

  Complaint: 21310129
  
  I am rejecting this response because:

  Community first health just wrote bunch of non sense excuse. I am sike from last November 2023 , stile my second referral, From March 18, 2024  I am waiting , tile July 22,2024 to see an ENT in network .  Is this faire to hold the patient for about second 100 days by not authorizing to see outside the network Doctor? My phone # is *************) C.F. is calling wrong number and expecting to talk to me. I called them today and   left massage , they did not returned my call yet.  C. F. is the the one coordinated me to go to see Urology outside network, but  C.F.  never paying they bill ($1650.)  C.F. wants me wraith for 100 days more  tile  to see a ENT Doctor in the network. Community first forced me  by not authorizing me to see a doctor outside the network.  I am not happy at all . 

  Community health do not have enough ENT Doctor, that's why there is 100 days waiting  list, also CF do not understand when some one is sick and suffering, needs help and has to see a ENT ASAP. not second 100 days wraith.

  1- CF always looking for excuse not to help the patient. and not to pay patient bill. 

  2- CF do not have enough Doctor also CF has a big , huge members.  Just for your info. Pt. asking to see a Doctor not a Nurse. 

  3- Network Doctor did surgery on my L. eye. She blind me I can not **** any more on my L  eye. 

  4- I am suffering and need to see ENT doctor ***** not several months leather.

  Regards,

  
  *******************************

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