Business ProfileforCarePlus Health Plans, Inc.

Dear Better Business Bureau,

I am writing in response to the inquiry you submitted to CarePlus on behalf of ******************************. We have researched the concern and identified the following:

As per the Center for ******** and ******** Services (CMS) guidelines, CarePlus Health Plan (CPHP) has 14 days to make a determination for a standard authorization request and 72 hours for an expedited authorization request. When an authorization is approved, the beneficiary's ******* Care Physician (***)has access to the submitted authorization through a delegated portal. In the case of an expedited organization determination, the beneficiary receives a phone call. If CarePlus is unable to reach them, a voicemail is left, and/or a letter is sent notifying them of the decision. If the authorization is denied,the beneficiary has the right to appeal the decision within 60 days of the date of denial.

According to CarePlus records, on January 17, 2024, the beneficiary's ***, ***************************, submitted an authorization for office visits with gastroenterologist **************************, which was approved that same day under authorization number 14857490*PO for three visits expiring on January 16, 2025. Furthermore, on July 9, 2024, the beneficiary's *** submitted an expedited authorization for a colonoscopy and biopsy with ************** at *****************, which was approved on July 10, 2024, under authorization number 15367084*OS for one visit,expiring on October 9, 2024. CarePlus contacted the beneficiary and left a voicemail advising of the authorization approval and instructed them to contact CarePlus ****** Services or their *** for further information about the approved service.

Moreover,the Grievance and Appeals Representative reached out to the office of *** ************************** and requested a review of their records. The office reported that they first received the referral request for the colonoscopy on July 2, 2024,and that it was submitted to CarePlus Health Plans for review and determination on July 9, 2024. The office received the approved authorization on July *******, and it was faxed to the specialist that same day. As per the office policy of **************, once they receive a referral request from a specialist,they will process and submit it to the health plan within 72 business hours.Once it is approved by the plan, they will fax it to the specialist. The office of ************** clarified that they were closed on July 4 and July 5 of 2024, for the holiday.

Please note that the *** is responsible for providing routine health care needs and overseeing care. If the beneficiary requires certain types of covered services or supplies from network providers, they must obtain approval in advance from their ***, such as getting a referral. All communications with medical offices are conducted through the Provider ********************** and provider offices can always contact CarePlus Provider Services for assistance. For authorizations, all providers have access to submitting and receiving approvals via an electronic portal.

Furthermore,a Grievance and Appeals Representative contacted the beneficiary on July 1******, to offer further assistance. During the call, the beneficiary advised that she only needs a colonoscopy and that she is currently scheduled to have it completed with gastroenterologist ************** on October 2, 2024. The Grievance and Appeals Representative offered to assist in finding a new gastroenterologist with an earlier appointment; however, the beneficiary declined as they preferred to have ************** perform the colonoscopy.Therefore, we contacted ******************************* office at *****************. They confirmed that the beneficiary is scheduled for a colonoscopy on October ******. Their records indicate that the beneficiary was previously scheduled for the colonoscopy on July 10, 2024. The office indicated that no sooner appointments were available. We inquired if they have a waitlist for cancellations to help the beneficiary get an earlier appointment, but they do not have one. Due to high demand, there is limited availability for these procedures. Some providers are scheduling appointments as far out as February.

In regard to the wait of the call center, we apologize for any inconvenience regarding the expressed concern. We are currently experiencing higher than normal call volumes and are working diligently to resolve this issue. Wait times fluctuate throughout the week based on member demands. We appreciate their concern and sincerely apologize for any inconvenience caused.

Thank you for alerting us about this issue. We value our relationship with our members and take all complaints seriously.

Best Regards,