ComplaintsforUltimate Health Plans, Inc.

• Initial Complaint

  10/24/2024

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  Ultimate authorized dental services for a special needs Insured prior to the treatment. The dental care was provided on 09/18/2024. The procedure was under anesthesia as the Insured has profound autism. Ultimate has ignored all efforts to resolve this and has provided no customer service to an Insured who relies on Ultimate to be an honest insurance company. Clearly Ultimate does not care about its Insureds.

  Business response

  10/30/2024

  On 10/03/2024, a grievance was filed regarding the partial denial of predetermination by the member's authorized representative. The members had paid out of pocket for dental services rendered by dental provider on date of service in question, which they believed should have been covered.

  On 10/28/2024, the plan contacted the dental vendor to investigate potential errors in the denial-of-service in question, and requested a review of the predetermination, attaching proof of payment for potential refunds. On the same day, the plan emailed the dental vendor to clarify that codes in questions appeared to have been denied incorrectly.

  On 10/30/2024, the dental vendor confirmed that the denials for those codes were indeed errors and that predetermination in question was sent for reprocessing. The plan then sought clarification on the reimbursement process for the member's out-of-pocket payment for covered benefits. The dental vendor responded that the dental provider had not yet submitted any claims regarding the date of service in question. They advised that if the members preferred immediate reimbursement, they could process a refund and later recoup the funds from the dental provider.

  The plan requested the dental vendor to proceed with an immediate reimbursement to the member. The dental vendor then asked for an itemized statement, which the plan provided later that day. After confirming that the documentation was sufficient, the dental vendor requested ***** days to process the refund. Despite several attempts to contact the membersauthorized representative on 10/28, 10/29, and 10/30, the plan was unsuccessful in reaching them. On 10/30/2024 the plan mailed the members authorized representative a please contact the plan for additional information notice. 

• Initial Complaint

  04/27/2022

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Ultimate was to give me 130.00 a month from Jan to April. Never received a dime. They owe me this money I want it. Called them do not get a satisfactory response. I joined the plan because of the $130.00 a month. Please contact them and resolve this.

  Business response

  06/06/2022

  Business Response /* (1000, 5, 2022/05/10) */ Acknowledging receipt of this complaint, however, when I try to locate the member in our system I am unsuccessful. Did the member provide a member ID for Ultimate Health Plan or a different name she might go by? Unfortunately, I am unable to proceed with this member's complaint without this information. Thank you, Ultimate Health Plans, Inc. Sarah N**** Grievance & Appeals Manager Ultimate Health Plans, Inc. 1244 Mariner Blvd, Spring Hill, Florida ***** Direct: ************** Main: ************** Fax: ************** ********************************************** Consumer Response /* (3000, 7, 2022/05/10) */ (The consumer indicated he/she DID NOT accept the response from the business.) I was a member of Ultimahl Health care. Give them my ID number UXXXXXXX. I was a member from 1/22 to 4/22. Consumer Response /* (3000, 10, 2022/05/14) */ I have never sent me my money Business Response /* (4000, 12, 2022/05/18) */ The member was enrolled in Premier by Ultimate (***********) with an effective date of 01/01/2022. The member voluntarily disenrolled with the plan with a termination date of 04/30/2022. While enrolled with Ultimate Health Plans, the member was entitled to a Part B Premium Reduction of up to $130.00 per month. Per the Evidence of Coverage for Premier by Ultimate that is provided to all members, chapter 1, section 7, page 16, Medicare Part B premium is automatically deducted from the member's monthly Social Security check. While the member is enrolled in this plan, Ultimate Health Plans will pay up to $130.00 of the member's Medicare Part B premium. As a result, the member's monthly Social Security check will increase by this amount. It can take the Social Security Administration several months to complete this process. This means the member may not see the increase in their Social Security check for several months after the effective date with this plan. Any missed increases will be added to their next check after processing is complete. If the member disenrolls from this plan, the member's Part B Premium Reduction will end on the date of disenrollment. Upon enrollment with the plan, members are educated on how the Part B Premium Reduction works by the sales team. On 02/01/2022, the member called into the plan to inquire about the $130.00 Part B Premium Reduction. She was advised by a customer service rep that it could take up to six months to see the reduction in her Social Security check and was advised that she will be reimbursed from the first month of enrollment. On 04/06/2022, the member called back into the plan to again inquire about the Part B Premium Reduction. The member was again educated by a customer service rep about the Part B Premium Reduction and was advised to call Social Security to request an itemized statement as the plan does not have access to this information. On 04/07/2022, the member again called the plan to inquire about the Part B Premium Reduction. The member was again advised by a customer service rep that it can take up to six months to see the reflection in her Social Security Check and was again advised to call Social Security. On 04/15/2022, the member again called into the plan about "getting her money" from Ultimate. The customer service rep tried to explain to the member that she would be getting a Part B Premium Reduction and that the plan does not send out money to members, however, the member did not want to hear the customer service rep's explanation and disconnected the call. The plan was able to verify through the CMS Enterprise portal that the member's Part B Premium Reduction from 01/01/2022-04/30/22 was accepted by the Social Security Administration on 04/22/2022. However, Ultimate Health Plans does not have access to the member's Social Security account, therefore, is unable to verify if the member is able to see the reflection in her Social Security check. The member would have to call SSA to request an itemized statement.

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