BBB Accredited Business since

EmblemHealth

Additional Locations

Phone: (888) 447-7074 55 Water Street, New York, NY 10041 http://emblemhealth.com View Additional Web Addresses


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Description

EmblemHealth, Inc., through its companies Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP), provides quality health care coverage and administrative services to approximately 3.4 million people. Groups and individuals can choose from a variety of PPO, EPO and HMO plans, as well as coverage for prescription drugs and dental and vision care. EmblemHealth offers a choice of networks, including quality doctors and other health care professionals throughout the region, leading acute care hospitals across the tri-state area, and physicians and hospitals across all 50 states. With EmblemHealth’s small group plans, members get the personalized care and comprehensive coverage they need and deserve.  If you are considering EmblemHealth plans, please call 888-447-7074.  For more information about EmblemHealth, visit www.emblemhealth.com.


BBB Accreditation

A BBB Accredited Business since

BBB has determined that EmblemHealth meets BBB accreditation standards, which include a commitment to make a good faith effort to resolve any consumer complaints. BBB Accredited Businesses pay a fee for accreditation review/monitoring and for support of BBB services to the public.

BBB accreditation does not mean that the business' products or services have been evaluated or endorsed by BBB, or that BBB has made a determination as to the business' product quality or competency in performing services.


Reason for Rating

BBB rating is based on 13 factors. Get the details about the factors considered.

Factors that raised the rating for EmblemHealth include:

  • Length of time business has been operating
  • Complaint volume filed with BBB for business of this size
  • Response to 65 complaint(s) filed against business
  • Resolution of complaint(s) filed against business


Customer Complaints Summary Read complaint details

65 complaints closed with BBB in last 3 years | 28 closed in last 12 months
Complaint Type Total Closed Complaints
Advertising/Sales Issues 3
Billing/Collection Issues 24
Delivery Issues 5
Guarantee/Warranty Issues 0
Problems with Product/Service 33
Total Closed Complaints 65

Customer Reviews Summary Read customer reviews

0 Customer Reviews on EmblemHealth
Customer Experience Total Customer Reviews
Positive Experience 0
Neutral Experience 0
Negative Experience 0
Total Customer Reviews 0

Additional Information

BBB file opened: October 21, 1992 Business started: 01/01/1947 in NY Business incorporated 01/01/1947 in NY
Type of Entity

Corporation

Business Management
Mr. Frank J. Branchini, Chairman and Chief Executive Officer Mr. William C. Lamoreaux, Executive Vice President, Corporate Operations
Contact Information
Principal: Mr. Frank J. Branchini, Chairman and Chief Executive Officer
Customer Contact: Ms. Alecia Henry, Manager, Grievance and Appeal Department
Principal: Mr. Anthony L. Watson, Chairman and Chief Executive Officer
Business Category

INSURANCE-HEALTH INSURANCE COMPANIES

Alternate Business Names
ConnectiCare of New York, Inc. EmblemHealth Administrators EmblemHealth Family Dental Practice EmblemHealth Neighborhood Care EmblemHealth Services Company LLC. GHI (Group Health Insurance) GHI HMO Select, Inc., Group Health Incorporated HMO Health Insurance Plan of Greater New York Vytra Health Plans

Additional Locations

  • 206-20 Linden Boulevard

    Cambria Heights, NY 11411

  • 215 West 125th Street

    New York, NY 10027

  • THIS LOCATION IS NOT BBB ACCREDITED

    3251 Hollywood Boulevard, Suite 401

    Hollywood, FL 33021

  • THIS LOCATION IS NOT BBB ACCREDITED

    374 Delaware Avenue

    Buffalo, NY 14202

  • 395 North Service Road, Suite 110

    Melville, NY 11747

  • 441 Ninth Avenue

    New York, NY 10001

  • 55 Water Street

    New York, NY 10041

  • THIS LOCATION IS NOT BBB ACCREDITED

    80 Wolf Road

    Albany, NY 12205

  • 87 Bowery

    New York, NY 10002

  • THIS LOCATION IS NOT BBB ACCREDITED

    Pioneer Business Park5015 Campuswood Drive

    East Syracuse, NY 13057

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BBB Customer Review Rating plus BBB Rating Overview


BBB Customer Reviews Rating represents the customers opinions of the business. The Customer Review Rating is based on the number of positive, neutral and negative customer reviews posted that are calculated to produce a score.

Customer Review Experience Value
Positive Review 5 points per review
Neutral Review 3 points per review
Negative Review 1 point per review

BBB letter grades represent the BBB's opinion of the business. The BBB grade is based on BBB file information about the business. In some cases, a business' grade may be lowered if the BBB does not have sufficient information about the business despite BBB requests for that information from the business.
Details

BBB Letter Grade Scale

BBB Rating Value
A+ 5
A 4.66
A- 4.33
B+ 4
B 3.66
B- 3.33
C+ 3
C 2.66
C- 2.33
D+ 2
D 1.66
D- 1.33
F 1
NR -----
Star Rating scale

  Average Score
5 stars 5.00
4.5 stars 4.50-4.99
4 stars 4.00-4.49
3.5 stars 3.50-3.99
3 stars 3.00-3.49
2.5 stars 2.50-2.99
2 stars 2.00-2.49
1.5 stars 1.50-1.99
1 star 0-1.49

BBB Customer Review Rating plus BBB Rating is not a guarantee of a business' reliability or performance, and BBB recommends that consumers consider a business' BBB Rating and Customer Review Rating in addition to all other available information about the business. If the BBB Rating is NR then only Customer Reviews are used for the Star Rating.

Complaint Detail(s)

5/20/2015 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: Emblem requires my Pharmacy ( ****** ****** ***), a mail order business to have a authorization from my doctor to fill a prescription for ****** ( a ******** med) or they will not cover the drug even though it is in their formulary. They want medical records. I maintain if my doctor wrote the prescription that is all they need to know

Desired Settlement: Stop making me and my doctor jump through unnecessary hoops for me to get my meds. If my doctor wrote the script and my insurance covers it then they do not need an "authorization" from my doctor and they do not need any medical "backround" on me. This is an attempt to delay paying for a drug they are contractually obligated to supply payment for.

Consumer Response: 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 and the matter has been resolved.

Sincerely,

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



 

5/4/2015 Billing/Collection Issues | Complaint Details Unavailable
5/4/2015 Problems with Product/Service | Complaint Details Unavailable
5/3/2015 Problems with Product/Service | Complaint Details Unavailable
4/20/2015 Problems with Product/Service | Complaint Details Unavailable
4/16/2015 Billing/Collection Issues | Complaint Details Unavailable
3/16/2015 Billing/Collection Issues | Complaint Details Unavailable
3/11/2015 Billing/Collection Issues | Complaint Details Unavailable
2/6/2015 Billing/Collection Issues | Complaint Details Unavailable
2/6/2015 Problems with Product/Service | Complaint Details Unavailable
1/27/2015 Problems with Product/Service | Complaint Details Unavailable
1/21/2015 Billing/Collection Issues | Read Complaint Details
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Additional Notes

Complaint: EmblemHealth started re-processing old bills (over a year and a half) to hospitals and doctors withdrawing their payments and the providers asking me to pay. I believe EmblemHealth does that because I'm no longer a customer and although legally they have the right to do it, I find it unethical.

Desired Settlement: I want EmblemHealth to stop reprocessing old claims and leave them paid as they were for years now.

Consumer Response: 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 and the matter has been resolved.

Sincerely,

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



 

12/5/2014 Advertising/Sales Issues | Complaint Details Unavailable
11/5/2014 Problems with Product/Service | Complaint Details Unavailable
10/17/2014 Billing/Collection Issues | Complaint Details Unavailable
10/17/2014 Billing/Collection Issues | Complaint Details Unavailable
10/2/2014 Billing/Collection Issues | Complaint Details Unavailable
9/11/2014 Billing/Collection Issues | Complaint Details Unavailable
9/2/2014 Billing/Collection Issues | Complaint Details Unavailable
9/1/2014 Problems with Product/Service | Complaint Details Unavailable
8/21/2014 Delivery Issues | Complaint Details Unavailable
8/21/2014 Billing/Collection Issues | Complaint Details Unavailable
8/20/2014 Problems with Product/Service | Complaint Details Unavailable
8/6/2014 Problems with Product/Service | Complaint Details Unavailable
6/26/2014 Billing/Collection Issues | Complaint Details Unavailable
6/24/2014 Problems with Product/Service | Complaint Details Unavailable
6/11/2014 Delivery Issues | Complaint Details Unavailable
6/5/2014 Delivery Issues | Complaint Details Unavailable
5/18/2014 Billing/Collection Issues | Complaint Details Unavailable
4/28/2014 Problems with Product/Service | Complaint Details Unavailable
4/18/2014 Billing/Collection Issues | Complaint Details Unavailable
4/15/2014 Problems with Product/Service | Complaint Details Unavailable
4/11/2014 Billing/Collection Issues | Complaint Details Unavailable
3/27/2014 Problems with Product/Service | Complaint Details Unavailable
3/26/2014 Billing/Collection Issues | Complaint Details Unavailable
3/25/2014 Billing/Collection Issues | Read Complaint Details
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Additional Notes

Complaint: On July **, 2013, I went to my primary doctor for an annual physical checkup. I am entitled to annual physical exams according to my policy (please see Attachments 1 & 2). After my physical checkup, my primary doctor sent me to Quest Diagnostics to get routine blood tests done. I went on July **, 2013 to get the blood work done. On August **, 2013, I received two bills from Quest Diagnostics for $1,385.20 (See Attachment 3). EmblemHealth did not pay any portion of the bill (See Attachment 3). The blood tests were routine tests ordered by my physician, nothing extra (See Attachment 4 for blood tests performed). I have contacted Emblem several times and they refuse to pay for the blood tests without stating a reason. They only say blood work is not covered in the policy, but fail to show any benefit documents to confirm this. The summary (Attachment 1) and policy (Attachment 2) clearly state that I am entitled to an annual physical and clinical laboratory tests. There are no asterisks or footnotes to denote that blood tests are excluded, or if there are any exceptions or limitations to this. In fact, my physican also believes that I am entitled to routine blood tests and he was baffled by my bill from Quest Diagnostics. Otherwise, my physican would have informed me that blood work was not covered and I would not have gone to Quest Diagnostics to get it done. On that day, Quest Diagnostics also informed me that my blood work was covered by my insurance. Emblem has unethical business practices. They refuse to pay for health services that are clearly included in the policy. We are a non-profit organization, and we cannot afford to pay for outrageous health bills. We only use health services that we know are covered. EmblemHealth needs to own up to its responsibilities and pay for these clinical lab bills for routine blood work as stated in their policy. ** I cannot upload these attachments on this site. Attachments can be sent upon request.

Desired Settlement: EmblemHealth needs to pay $1,385.20 in health bills.

Business Response:

We never received authorization from the member.  Therefore, we cannot disclose any of the results regarding this case.  We responded directly to the member on 3/**/14.  I hope this helps.

Consumer Response: 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 and the matter has been resolved.

Sincerely,
**** ***



 

3/13/2014 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: My daughter had cause to visit the ER on June **,2013. Emblem Health claimed they issued a check for the resulting bill sometime in August of same year. It is February ,2014 and I have yet to see that cheque. I called them on January **, 2014 and spoke to a rep. giving her new address information since I had moved. She let me know a stop payment would be made on first cheque and a second one would be reissued. She also advised that I would receive said cheque within seven (7) to eleven (11) days. Today is February *,2014 and several calls later and I still haven't received anything. They are promising another wait of thirty (30) days. The situation is made even worse since the outstanding medical bill has gone into collections. How can this be allowed? How can this be fair when insurance premium has been paid faithfully and on time each month. This is disgusting!!!

Desired Settlement: Expedited delivery of service. My good credit is at stake!!

Business Response:

Here is the response we have on this member, member issue resolved , he recieved check.

Hi *** ******,

·         According to our system, he called our Customer Service Department on 1/**/14 to update his address as he moved to Greensboro NC.

·         On 1/**/14, a stop payment was placed on the check and it was reissued to him at his new address. 

·         The check was cashed on 2/**/14. 

·         The reason why he did not initially get the original check was because it was sent to his old address.  

·         I spoke to *** ****** on 2/**/14 and he informed me that he received the check and it was cashed.

I was waiting for the PHI form to be returned  to write to the BBB, but we have not received it to date.

Any questions please have member request update through Grievance and Appeal case # with Emblem Health.

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

Emblem Health, Customer Service

2/28/2014 Billing/Collection Issues | Complaint Details Unavailable
2/26/2014 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: I submitted a claim for medical care received on 1/**/2013 and the provider submitted the bill to GHI for processing ($665.00). GHI denied the claim saying that it was cosmetic (despite the fact that it was not, and similar charges had been filed and paid for the same condition in the past) I submitted the doctor's notes to appeal on May **, 2013 and received no communication from GHI. On July **, 2013 I send a message on their web site asking about the appeal and received a note back saying that they had received the paperwork and to please allow more time for review. I sent a note again on January **, 2014 to inquire about this claim as I still have received no communication regarding my appeal. Today I received a response from GHI, saying that they never received any appeal information for this claim, in the same thread that contained the original note indicating that they had received it.

Desired Settlement: I want them to pay the claim. I think its ridiculous that they require customers to submit appeals within 6 months but then expect completely open ended time to process the claim and then pretend that they don't have the information. This is the second time I have had to submit a complaint regarding this company to get them to honor a covered service.

Business Response:

Please review the attached response made by our Grievance and Appeal department in reference to this complaint submitted by the BBB on behalf of ************.

Member will be supplied with appeal rights she can follow if she wants to appeal decision.

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

12/24/2013 Problems with Product/Service | Complaint Details Unavailable
12/12/2013 Problems with Product/Service | Complaint Details Unavailable
10/9/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: GHI contracts with********* ****** to approve ************ treatment. Even though I have been diagnosed with a ******* **** *** ** ***, and have been prescribed ******* by medical doctor, ********* has initially denied paying for treatment. They delay my receiving treatment, while I am in pain, with continuous requests for more documentation.

Desired Settlement: Stop delaying treatment

Business Response: Dear *** *******:

This letter is to acknowledge receipt of and is in reply to your inquiry on behalf of *** *********, which was received on 09/**/13.

In accordance with the Health Insurance Portability and Accountability Act of 1996, we are prohibited from releasing Personal Health Information without a signed authorization to release information form from
*** *********.  Kindly be advised that we are in the process of investigating the issues and a response will be sent to *** ********* shortly.

10/1/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: On May **,2013, I had surgery for ****** ******.My ***** ****** *** ******* and I *** ****** ********* ** ** **** ******.I used an out of network plastic surgeon,*** ******.I am entitled to use out of network doctors according to the insurance company.My plastic has not been paid as of today, September **.When the doctor originally filed the claim,the company said documentation was missing.The doctor refiled the claim with the documentation over 35 days ago and they have still not been paid.I have called Emblem Health about this many times.customer service representatives keep telling me it has been approved, but it is a high dollar amount. Why should this take so long? I feel that I am being punished because I used an out of network physician.Also the doctor's office is now submitting me bills.It should not take this long to process a claim.All of my claims by network doctors have been processed.I feel as if the company is discriminating against non network providers.The claim should be paid in a timely fashion whether the doctor is in the network or out of the network.Currently I am in danger of losing my plastic surgeon if my bill is not paid.

Desired Settlement: Pay the bill

Business Response: Dear *** ******:

This letter is to acknowledge receipt of and is in reply to your inquiry on behalf of *** ********, which was received on 09/**/13.

In accordance with the Health Insurance Portability and Accountability Act of 1996, we are prohibited from releasing Personal Health Information without a signed authorization to release information form from
*** ********. Kindly be advised that we are in the process of investigating the issues and a response will be sent to *** ******** shortly.

******* ***********
Senior Specialist
Grievance and Appeal Department

9/12/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: I have a toothache since July*, my Dentist submitted a claim to my health insurance company for approval.. I received a response on July ** that it was denied because I was over 21 years and only could be approved if the #14 tooth supported a bridge which it did. someone did not notice the xray and documents from the dentist that I had a bridge. I have been trying to get the company to approve the claim because I am still in pain because I cannot afford the toothache I have been getting the run around. My phone calls are being ignored and no response. I even received a letter that I wanted to cancel my judgment which I have no concept. Allegedly they want me to get discourage.

Desired Settlement: I just wanted to have the matter resolved to avoid the endless tooth ache and the pain killer pills that they keep recommending and this is coming from the customer service representatives when I call, is that legal? I have the documentation from the insurance company about being over 21 years and only would be approved if it is supported by a bridge.

Business Response: Dear *** ********:
 
At HIP, we strive to provide you with access to a wide range of quality health care services that meet your needs.  So when we deny coverage for a treatment or service, we want to make sure you know why.

We are responding to your Action Appeal received on 7/**/13 for a referral for root canal therapy on tooth # 14.

Our Enrollment Department's records indicate that you are enrolled under a HIP Medicaid Managed Care Program. As per your Member Handbook, Part II, Your HIP Coverage, Page 12, Dental Services include: routine exams, x-rays, clem1ings, fillings, tooth pulling, emergency treatment, root canal and oral surgery (under certain conditions).

Please note that based on the NYS MMIS Guidelines, specific criteria must be met in order to provide coverage for a referral for root canal therapy.  Based on the information provided to us by Healthplex from your Healthplex participating provider, you do not meet the coverage requirements.

Your request was carefully reviewed and considered by a Consultant in  our Dental Department.

Using the information provided, the conditions present in your mouth and the NYS MMIS Guidelines, which are the criteria established by New York State to administer your dental benefits, we are upholding the initial denial.  This means that we will not cover the following services or items that you or your provider requested: referral for root canal therapy on tooth #14.



However, we suggest that you contact your general dentist to discuss functional alternatives and to ensure the continuity of your dental treatment.

If you have any questions about this decision, you or your authorized representative may call me at ###-###-#### or Customer Service at ###-###-#### or write to HIP Grievance and Appeal Department. ** *** ***** *** ***** ** **********.

What If I Don 't Agree With The Decision?

You may have the right to file a Fair Hearing if you  disagree with our decision. Please see the enclosed document: Important  Information  about vour Fair Hearing Rights for more information.

Sincerely,
***********

Consumer Response: Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID# *******, and have determined that my complaint has NOT been resolved because:

 

The insurance company refuses contact the dentist for the rest of the document to resolve the dilemma, I mentioned to the supervisor tha ** ***** told me to pay $300 in order to start the process. That illegal because I already have insurance. The pain an suffering started on th *** of July until today. All this finger pointing from the doctor to insurance company via versa. 

 

 

 

 

In order for the BBB to appropriately process your response, you MUST answer the question above.


Sincerely,

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




 

Business Response:

Dear *** *****,

The response letter was a formal Plan decsion on this member ( **** ********) and his complaint concerning denial of dental treatment for specific root canal. The letter provides the member with his appeal rights and next steps in pursuit of the final resolution for HIP Medicaid members through the State Fair Hearing process.

Emblem Health will not provide any further response until member files for and goes through Fair Hearing process as allotted by his coverage.

******* ******,
Senior Director Customer Service

6/3/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: Dear Customer Service, My Health Insurance EmblemHealth - certification number *********. I'm reporting fraud activity between GHI EmblemHealth Insurance and provider ****** ****** *** ***. I'm receiving durable medical equipment ****** ** ******** ******. Cash price for 1 box is- $350. On January **, 2013 GHI EmblemHealth paid ************ *** $ 1931.97 for 3 boxes (1 box for $643+ I paid co-payment $582) In November **, 2012 GHI EmblemHealth Insurance paid for 1 box - $309. From 10/**/12 until this time price was not change it still remain as $350 per box I called GHI on March *2013 and explained my concern. 1. they refused to file fraud accident, they round me on the phone over 1 hour, abusive screaming that I don't understand how insurance work, when I asked them question why they paid over three times no respond. 2. they did create claim #***********. They did investigation compare coverage in 5/**/12 (which was related not to ****** coverage) it was coverage for durable medical equipment nothing to do with ****** Customer Service refusing to provide information why GHI paid 3 times more for ******* and why I can only order from ****** ****** ***, they are not explaining why 3 month ago price was $309 and now GHI paid $643 + increasing my co payment? ****** ****** *** *** in network provider. A year ago I received same item from another company with less co payment and it was covered under pharmacy plan I'm asking you to provide investigation based on information above. If you have any question, please contact me email: ****************** ********* ****** ********** ******* *** ***** ****** *** ************ *** ************

Desired Settlement: GHI Emblem Health must allow me to continue to receive ******* from ****** ******* ******** ********, which charged GHI much less money. Explain reason why EmblemHealth not providing in network coverage with diabetic supplies it covered 100%. Why GHI paid 3 time more of original price

Business Response: Dear ** *******:
 
This letter acknowledges receipt of and is in response to the additional concerns you sent to ******** ******* at EmblemHealth on behalf of ******** ************* regarding the above listed case.
 
Due to HIPAA regulations, personal health information cannot be released to your office without a written authorization to release information from ******* ********. Therefore, we are reviewing the matter noted in your correspondence and will respond directly to the member.
 
If you need further clarification or require additional information, please forward your inquiry to the following address: EmblemHealth/GHI,  ********************************************, Attention:  ** ******* *******.
 
Sincerely,
** ********
Customer Service Rep
 

Business Response: **. *********, here is the response to *** ************ refusal of our initial response. *******

Consumer Response: Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID# *******, and have determined that my complaint has NOT been resolved because:


I received phone call from ****** ****** *** (billing office) telling me I have to pay balance. I asked what balance, for what date, she couldn't answer. She told me she would call me back. When she called me, she said, "you did right by complain to bbb, this is not our fault this GHI fault. I asked why your bill to GHI three times more plus my copayment, and you accept all payments. No answer. The letter from GHI blaming back to ****** ****** ***.   

Two weeks ago, I received ****** ** ******* from ****** Medical (under pharmacy coverage not under durable medical equipment), and it was covered 100%  

I made official complain to *** **** ****** ** *** ******** *******. This case is under investigation by ***** ******.  

I would like to keep complaint open until GHI and ****** ****** *** finalize what is going on, please.   

I'm appreciated for all your help. I received ******* from ****** with no problem. 

Thank you

Sincerely,
****** **********




 

5/31/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: I had placed an anthesia claim on 1-**-13 for services rendered on 1-**-13. I first mailed it in and GHI claimed they never received it. So I faxed it 3 seperate times after that which they claimed they still never received. Finally I was able to find someone to stay on the phone in the Syracuse office, named *** who did state he had received the claim and would send it to the claims department which he did. On 04-**-13 it was denied for incorrect medical coding. So on 04-**-13 a second fax was sent with the "correct medical coding" I was told it would take 15 business days for a result. Yet i still dont have an answer on 05-*-13. This is not the first time I have had issues with GHI in November 2009 a claim for anethesia due to a dental surgery took 7 months and 32 phone calls to get resolved. GHI customer service is located in several cities in the USA. Each has no idea what the other is doing. They cant speak to anyone in claims and they never call you back when they say they will. the doffrent cities cant speak to each other and have no way of contacting the corporate office. I never get one person I can deal with and they refuse to give me a single contact person. They figure if they stall long enough I will give up. My medical doctor refuses to accept GHI any longer because because he has claims in excess of $250,000 which they refuse to claim. So now I have to give him $45 out of pocket to get service.

Desired Settlement: I just want the $450.00 claim sent to me. I paid it out of pocket and it is covered as explained in the 2009 experience.

Business Response: Dear *** *****:

This letter is in response to your inquiry regarding your claim for services rendered by ******* ** ****, DDS on 1/**/13. Please note that your plan with EmblemHealth/GHI provides limited coverage for dental services rendered on teeth or gums.  The following are the dental related benefits that are covered under a patient’s medical contract:

• Extraction of impacted teeth.
• Reduction of fractures of the jaw or facial bones.
• Dental care or treatment rendered to treat congenital disease or anomaly.
• Dental treatment if the treatment is medically necessary when related to an accidental injury to sound teeth or repair sustained accidentally, provided that such treatment is performed within twelve (12) months of the accident.
• Treatment of salivary gland disorders.
• Cutting surgery on tissue of the mouth other than the gums and alveolar bone.  The surgery cannot be rendered in connection with the extraction, repair or replacement of the teeth.  Implants and implant surgery, including preparation of the alveolar process for the insertion of dental implants, are not covered.  Removal of cyst of dental origin is not covered.

The services billed via claim number **********, ********** (code *****), surgical removal of residual tooth roots (code *****), a consultation (code *****) and an Orhtopantogram (code *****) are not covered under your contract.  The applicable contract pages are attached with this response for your review.

Sincerely,

******** *************
Specialist
NYDFS Unit

5/6/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: Since October of 2012, I've been requesting my health care provider (GHI/EmblemHealth) to remove my son from my health care policy because he is already covered under his dad policy and their coverage is not needed since May of 2012. I've mailed, faxed, emailed them the written request and several times all the supporting documentation needed to grant said request because they several times claim that they never received said documentation, (Cigna certificate of coverage letter from my son and his health care insurance card), to remove him from my policy. As of today, they are still billing me for my son and still has him active on my account and refuse to adjust my monthly bill forcing me to pay for his coverage or I will lose my coverage if I do not pay the bill in full. Even though it has been almost 6 months of such ordeal they haven't issue me a refund or the removal of my son from my policy. they continue to charge me monthly for insurance coverage he doesn't need. I call their customer service department on a weekly basis and each time there is a new version of why my son still active on the account. Nobody seems to be able to explain their negligence and abuse in forcing me to pay for a coverage that is putting a strain on my finances. I can not stop paying the policy altogether.

Desired Settlement: Remove my son immediately and issue a refund for the premiums i have been paying.

Business Response:  
We are in receipt of the Cigna Certificate of Coverage letter for *********** ********* showing the effective date of 05/**/12.  Our records show that claim payments were issued to the providers for the services rendered on 06/**/12, 06/**/12 and 08/**/12.  Enclosed are copies of the Explanation of Benefits statements for your review.  As a result, we have terminated the enrollment of *********** ********* effective September *, 2012, the first of the following month subsequent to the last date of service.  An adjustment/credit has been made relative to the change from employee and child to an individual policy as follows.
 
******** **** ***** ************** ******** **** ******** * ********* ********* ********** ******* **** ******** * ********* ********* ****** **** ********* 
We ask that you allow approximately ten (10) business days from the date of this letter for receipt of the refund.
 
 
 
Sincerely,
 
******* ***********
 
******* ***********

Consumer Response: Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID# *******, and have determined that my complaint has NOT been resolved because:

 

I contacted GHI EmblemHealth customer service yesterday and was told that there was no record that a refund was going to be issued on this matter. Rather, they informed me that they have decided to credit my account and deduct my monthly premium from the over payments they forced me to make up until last month.

I want a full refund of all the overpayments as it is says on the letter the sent you. My hesitation in closing the matter is that they have shown so much negligence in removing my son from my policy that now I fear they will keep the money and never issue a refund without another fight.

Thank you so much for your great help and understanding.

Sincerely,


*** *****

 

 

 

In order for the BBB to appropriately process your response, you MUST answer the question above.


Sincerely,

*** *****




 

5/4/2013 Delivery Issues | Read Complaint Details
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Additional Notes

Complaint: I was a member of Emblem Health via the NY Bridge Plan beginning in December of 2011. I have paid my premiums in the timely manner using, with the exception of one month, money orders because of the processing time required for checks. I purchased a money order for my February payment on 2/*/2013 and mailed the payment. Evidently, the payment did not arrive in time to prevent automatic cancellation of my coverage. The company, however, cashed the money order on 2/**/2013 but failed to reinstate my covereage. Since I was unaware that my coverage had been suspended, I mailed my March payment (dated 3/*/2013). I have been ill with various problems since December but had been taking care of myself until March **** at which time I attempted to obtain a prescription from my local pharmacy. My insurance was turned down at that time and the cancellation of my policy prevented me from obtaining emergency care at that time. I contacted Emblem Health several times over the next few days and was told that my coverage had been cancelled as of February *, 2013. I have screen captures from my online account to prove that fact. A customer service representative found no evidence on that during a conversation on March ****. On Monday, March ****, I spoke with customer service and told them to make a note that, rather than reinstatement (which had not happened in spite of my requests to find my payments), I wanted a refund for my February and March payments totalling $724.00. The next day, they reinstated my coverage in spite of the fact that they had yet to credit my March payment which had been cashed on the **** of March. They have now reinstated my coverage and obviously have disregarded my request for a refund in spite of the fact that they had received and cashed my payments and still refused to cover my expenses when they were needed. Basically, they want this both ways: to refuse coverage when needed and to keep the payments. I will be eligible for Medicare starting in April of this year so they are aware that I will not longer be their problem very soon. Given that I paid for coverage that I did not receive when needed and that lack of coverage prevented me from seeking help during a medical emergency, I feel that a refund the those two months is in order and appropriate. Incidentally, my online account reflected reinstatment as of 3/**/2013 and there was no record of my cancellation which had been previously accessible.

Desired Settlement: Refund of my February and March payments totalling $724.00.

Business Response: Dear *** *******:
 
 
This letter is in response to an inquiry received on your behalf from the NY Better Business Bureau
regarding your membership.
 
 
Please be advised that we have honored your request to terminate your membership effective February *, 2013. A refund in the amount of $724.00 representing the premium payments received for February 2013 and March 2013 is in process.  We ask that you allow approximately ten (10) to twelve (I 2) business days from the date of this letter for receipt of the refund.
 
We apologize for any inconvenience you may have experienced in attempting to resolve this matter.
 
 

Consumer Response: 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 and the matter has been resolved.

Sincerely,

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



 

4/11/2013 Billing/Collection Issues | Read Complaint Details
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Complaint: Emblem Health has failed to cover emergent services provided by a non-par provider to their member despite state and federal laws prohibiting this practice.

Desired Settlement: Become comliant with state and federal statutes regarding coverage for emergent services.

Business Response: Dear ** *******:
 
This letter is to acknowledge receipt of and is in reply to your inquiry on behalf of ** *****.
 
Please be advised that ** ****** identification number is required so that we may investigate and respond to the complaint.  The information should be sent to GHI/EmblemHealth, *************************************, Attention: ****** ********.  Please include a copy of this letter with your response.
 
Sincerely,
******* **** *****
Administrator NYDFS Unit

3/20/2013 Problems with Product/Service | Read Complaint Details
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Complaint: I sent in an application for the Cobra Health Plan for my husbdand and I that was due on 12/*/12. I sent it overnight through the post office on 12/*/12. When I called the Emblem each week to follow up, they said give it 30 days. Finally after the 30 days, they still did not receive the package. When I checked USPS tracking, it showed that the package was sent but not delivered. Now I needed to know how to proceed since it was now past my deadline, but I had proof that I sent out the application overnight a few days before the deadline. After speaking to an overwhelming number of people who couldn't give me a direction to go, and hours later, I asked to speak to a manager. I was placed on hold for a half hour and then was disconnected. I called back and finally requested tp speak to a manager again. The woman said the manager was out to lunch and would call me back. She never did. I called 2 days later, and finally got the manager. She was not at all sympathetic, but told me that since they didn't receive it, & I had proof from USPS that it was sent out, to send a new application along with the proof and ask enrollment to please expedite. I went to the post office and got proof that my package was sent overnight on 12/*. I sent back the new application, along with all the proof that my application was sent within the time of the deadline. The application was received and signed by Emblem on 1/**/2013. I called to follow up a week later and they still had no record of it. After a couple of weeks of following up and getting nobody to help me, a new rep told me to fax the application. I did that, followed up and they "didn't receive it." I called again and was instructed to fax it yet again. I have spent the last 3 months resending my applications through mail and through fax. The lady that gave me the fax number said to follow up 2 business days later. I have been following up, and now its 11 days after I sent the second fax, and I am told by "*** ********" that its too soon, they need 7-10 business days to process after its received. I said "It has been 11 days." She was nasty and unhelpful and finally told me maybe I should try back next Tuesday (in 8 more days). So to summarize, I have been getting the runaround for 3 months and still have no answers. My application has apparently still never been received even though I have delivery confirmation on 1/**/2013 from my second mailed application, and confirmation on both faxes that they went through. They still "have nothing", and I am still without health insurance.

Desired Settlement: To "find" and process my application as well as my husband's

Business Response: This is to acknowledge receipt of your correspondence submitted on behalf of *** **** ***** *******, which was received by our Grievance & Appeal Department on 2/**/13.
 
Based on the Health Insurance Portability and Accountability Act  of  1996(HIPAA), which protects member privacy and the confidentiality of personal health information, we are unable to disclose the outcome of our investigation to your office without the member's authorization. Enclosed please find the HIP Health Plans Authorization to Use and Disclose Protected Health Information Form. If the member signs and returns this document to HIP, authorizing HIP to correspond directly with your office, you will be advised of the outcome of our investigation. However, if this document is not signed by the member and returned to us, we will investigate the concerns addressed in your correspondence and we will only respond directly to the member.
 

Thank you for taking the time to bring the member's concerns to our attention.
 

3/18/2013 Advertising/Sales Issues | Read Complaint Details
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Complaint: Emblem Health never informed me that my PPO High Option (GHI Medicare Choice PPO) rates for 2013, were increased by 33% (from 99.00 to 132.50) . During the Election Period, had I known that my rates were being increased by 33%, I would have elected to search for a better health plan that meets my fixed income. I only found out about the 33% increase when I received my "New Benefits Amount" statement from Social Secuirty, in Jan 2013. I am a Senior Citizen and my only income is my Social Secuirty distribution. I contacted Emblem Health in regards to their failure to notify me about their substantial increased rates and, the fact that this deprived me of any chance of changing medicare supplemental plans. Their response was that they sent out the package 9/**/2011. I never received the package nor the new Emblem Health card. I have been at my address for over 7 years and I have received Emblem Health update booklets and letters, regarding service providers and Updates but I never received any mail, emails or any communications regarding the 33% increase in my current health plan. My complaint is that Emblem Health failed to notify me of the substantial increase, monthly, in my health plan and denied me the opportunity to re-evaluate my medicare supplemental plan during the period of time we are able to elect to change plans. I told the Emblem health representative that they definitely need to send a certified "follow up" letter for Senior Citizens to acknowledge, whenever they increase their Supplemental Medicare rates by 33% or more BECAUSE many of us are on fixed incomes and we need to have that opportunity to change plans, when this happens. The Emblem Health representative was not concerned about my problem and merely reiterated, they sent the Emblem Health booklet out and I am stuck with these high monthly rates. I don't know how many more Senior Citizens are in the same dilemma.

Desired Settlement: My main complaint is that Emblem Health NEVER provided me with the 33% rate increase and more importantly, deprived me of that open window, last year, where I could have changed my Supplemental Medicare plan. I need a Billing adjustment reto to last years rates because they deprived me of an opportunity to change Supplemental Medicare plans, during the open window. We also need Emblem Health to realize that a 33% increase in plan rates can be very costly to Senior Citizens on a fixed income and they need to send a certified letter to their constituents, WHENEVER they plan to raise their rates by 33%, so these Senior Citizens can plan accordingly, during the Open Window, for changing plans.

Business Response:  
EmblemHealth Medicare PPO has received your recent grievance on behalf of *** ******* on 02/**/2013 in which you referenced *** *******'s dissatisfaction with the method in which we notify our members of annual changes to their premium. The details of your grievance are being reviewed.
 
You will be notified of the outcome within 30 days of our receipt. We may extend the time frame by up to 14 more calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If the extra days are needed you will be notified.
 
If you have any questions, or if this information is incorrect, please call me at ###-###-####, Monday through Friday, 9:00am to 5:00pm or you may contact Customer Service at ###-###-####, Sunday through Saturday from 8:00am to 8:00pm. If you have a hearing or speech impairment and use a TDD, calll-###-###-####, Sunday through Saturday from 8:00am to 8:00 pm.
 
Sincerely,

Business Response: This letter is in response to your recent letter to EmblemHealth Medicare PPO on February **, 2013 in which you referenced *** *******'s dissatisfaction with the method in which we notify our members of annual changes to their premium and the increase that occurred for 2013.

In your correspondence, you informed us that *** ******* contacted the Better Business Bureau because he was never informed that the premium for his EmblemHealth Medicare High Option PPO would increase by 33% for 2013. He states that, if he knew this was going to occur, he would have elected to change health plans. He states that he found out that the change occurred when he received his "New Benefits Amount" statement for Social Security in January 2013. He states that he was told by EmblemHealth that we sent our notification of his plan changes on 09/**/2012, however he never received the package. He states that EmblemHealth should send a certified "follow up" letter for Senior Citizens to acknowledge whenever rates are increased.

Upon receipt of your inquiry, we forwarded your concerns to our Marketing Department for review. Our Marketing Department's records indicate that the member's Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) packet for 2013, which notified him of all changes to the plan including premium increases, was mailed to *** **** ******* ********* ***** ********* ** ********** on 09/**/2012. According to the ANOC, *** ******* was notified that his premiums were increasing from $94.00 per month in 2012 to $132.50 per month in 2013. Enclosed are the applicable pages, indicating notification of the change in premium amount. Our records do not indicate that the packet was returned, nor was delivery confirmation part of the ANOC/EOC mailing this past year as it is not a requirement set by the Centers for Medicare and Medicaid Service (CMS).

Please note that EmblemHealth has made every effort to continue to provide our members with quality healthcare at an affordable cost. Although there is an increase in to *** *******'s premiums, there were very few changes made to his benefits. Most of his cost sharing, such as copayments and coinsurance, did not change. The premium rates are approved by CMS after a review of the benefit and rate submissions.


Group Health Incorporated (GH!), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to EmblemHealth companies.

EmblemHealth Medicare PPO takes the comments and concerns of our enrollees very seriously. A permanent file is retained for all complaints. The information in these files is used to evaluate the performance ofEmblemHealth Medicare PPO.
 
If you have any questions, you may contact Customer Service at ###-###-####, Sunday through Saturday from 8:00am to 8:00pm. If you have a hearing or speech impairment and use a TDD, call  ###-###-####, Sunday through Saturday from 8:00am to 8:00pm.
 
Sincerely,

Consumer Response: Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID#*******, and have determined that my complaint has NOT been resolved because:

 

[To this very date, 03/**/2013 I HAVE NOT RECEIVED THE CHANGES TO MY EMBLEM HEALTH POLICY. ADDITIONALLY, I RECEIVE NUMEROUS LETTERS FROM EMBLEM HEALTH REGARDING PROVIDERS CHARGES, BUT I NEVER RECEIVED A NOTIFICATION THRU EMAIL, PACKAGES OR TELEPHONE COMMUNICATIONS, THAT MY RATES INCREASED FOR 2013, BY 33 PER CENT. I RECEIVED A PHONE CALL IN JANUARY- AN EMBLEM HEALTH REPRESENTATIVE WANTED TO COME OVER TO MAKE SURE I UNDERSTOOD POLICY CHANGES- THIS SHOULD BE DONE AS A "FOLLOW UP" DURING THE "OPEN WINDOW", WHEN THE RATES INCREASE BY 33 PERCENT.

MY ONLY SOURCE OF INCOME IS MY SOCIAL SECURITY AND THIS INCREASE IS TOO MUCH OF A BURDEN.

AGAIN, I FEEL CMS SHOULD BE RESPONSIBLE FOR ENSURING THAT EMBLEM HEALTH CHECK TO ENSURE SENIOR CITIZENS WITH A 33 PERCENT RAISE IN HEALTH EXPENSES, BE CALLED AND NOTIFIED THAT THERE IS A BIG INCREASE IN THE CURRENT PLAN, DURING THE OPEN WINDOW PERIOD. IF THE EMBLEM HEALTH REPRESENTATIVES CAN CALL YOU AT THE BEGINNING OF THE YEAR ABOUT YOUR ROLLOVER PLAN, THEY SOULD CERTAINLY CONTACT YOU DURING THE "OPEN WINDOW" PERIOD, TO MAKE THE SENIOR CITIZEN AWARE OF THE DRAMATIC INCREASE IN THEIR PLAN.

IF I DON'T GET A BETTER RESPONSE FROM EMBLEM HEALTH, I MAY TAKE THIS MATTER TO MY PARTY REPRESENTATIVES AND, COMPLAIN TO CHANNEL 7 EYEWITNESS NEWS, TO HAVE LEGISLATION CHANGED TO PROTECT SENIOR CITIZENS FROM GOING THRU THE FINANCIAL BURDEN I AM GOING THRU. WITH EMBLEM HEALTH. THEY DEFINITELY NEED TO FOLLOW UP THRU A PHONE CALL TO SENIOR CITIZENS, WHEN THEIR RATES GO UP BY 33 PERCENT. AGAIN, IF THEY CAN CALL ME AT THE BEGINNING OF THE YEAR TO ASK ABOUT SATISFACTION WITH THEIR PLAN (WHICH THEY DID), THEY CAN CERTAINLY CALL DURING THE OPEN WINDOW, TO FOLLOW UP, REGARDING 33 PERCENT RATE HIKES.

AGAIN, MANY SENIOR CITIZENS ARE ON A SINGLE, FIXED INCOME.

 

 

 

 

In order for the BBB to appropriately process your response, you MUST answer the question above.


Sincerely,

**** *******




 

3/7/2013 Problems with Product/Service | Read Complaint Details
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Additional Notes

Complaint: To Whom it may concern,A HIP customer representative told me on February **, 2013, that I was covered to see a ********** without a referral. They also added that I had no copay. I saw the **********. Today, February **, 2013, the ********** told me to check again with my insurance because he believes that I needed a referral by my doctor.Surprisingly today a different HIP customer representative told me that unless I am a ******** I have no coverage to see a **********. They also state they do not have any history on my file that I called them in the past in regards to ******** treatment. My cell phone records prove that I did in fact call them. Now I am expected to pay out of pocket for the insurance company's failure to provide the correct information.Sincerely,

Desired Settlement: Payment to my doctor.

Business Response: Dear ** *******:

February **, 2013
 
RE: ******* ******** ******** ***********
LOB: ***
Group/Coverage Type: **********
Plan Name: *** ****** **** ***** ****
Underwriting Entity: ***

This is to acknowledge receipt of your correspondence submitted on behalf of ** ******* ********, which was received by HIP's Grievance & Appeal Department on 2/**/13.
 
Based on the Health Insurance Portability and Accountability Act of  1996(HIPAA), which protects member privacy and the confidentiality of personal health information, we are unable to disclose the outcome of our investigation to your office without the member's authorization. Enclosed please find the HIP Health Plans Authorization to Use and Disclose Protected Health Information Form. If the member signs and returns this document to HIP, authorizing HIP to correspond directly with your office, you will be advised of the outcome of our investigation. However, if this document is not signed by the member and returned to us, we will investigate the concerns addressed in your correspondence and we will only respond directly to the member.
 
Thank you for taking the time to bring the member's concerns to our attention.
 
Sincerely,

**** ***** 
Senior Director
Grievance and Appeal Department

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