Synopsis of Facts Sample Clauses

Synopsis of Facts. This matter concerns the failure to timely issue a written determination for a provider dispute. In December 2017, a health care provider filed in paper form a provider dispute regarding a claim for health care services. The Plan received the dispute on January 2, 2018, and acknowledged receipt on January 4, 2018. Due to an administrative error, a resolution letter stating the pertinent facts and explaining the reasons for the Plan’s determination of the dispute was not sent to the provider.

Synopsis of Facts. This matter concerns the improper denial of a claim. In August 2020, the enrollee received emergency health care services in a foreign country, which was not covered by Medicare. She submitted claims to the Plan as she had coverage under an Anthem Medicare Supplement Innovative Plan F. The Plan denied coverage pending additional information from the enrollee regarding Medicare. Shortly thereafter, the enrollee attempted to gather the additional information from Medicare. After the efforts were fruitless, the enrollee filed a complaint with the Department. During the Department’s investigation, the Plan indicated the additional information was unavailable. Consequently, the Plan adjusted the claims for payment and issued an updated explanation of benefits. / / / Blue Cross of California January 20, 2022 Xxxxx Xxxxxx Page 2 of 3

Synopsis of Facts. This matter concerns the Plan operating at variance with an Evidence of Coverage (EOC) and infractions related to a grievance. During the relevant period, an enrollee had a Point of Service (POS) health plan. The EOC provides that non-emergency health care services provided at an in-network facility by an out-of-network provider, not chosen by the enrollee, are reimbursed at the maximum allowed amount. The enrollee will pay no more than the network cost sharing amount. In January 2021, the enrollee received medical services from an in-network provider at an in-network facility. An out-of-network anesthesiologist at the facility rendered medical care (Subject Services). The claim was adjusted using the benefit provisions for out-of- network providers. In March 2021, an authorized assistant disputed the amount allocated to the claim (Grievance). The letter expressly notes that the patient did not have a choice on who the anesthesiologist would be for the covered health care services. Although the Plan Enforcement Matter Number.: 21-782 Document Number.: 377312