Case 1:22-cv-01341-WMR Document 1-1 Filed 04/06/22 Page 1 of 47
`Case 1:22-cv-01341-WMR Document1-1 Filed 04/06/22 Page 1 of 47
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`EXHIBIT A
`EXHIBIT A
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`

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`DO NOT WRITE IN THIS SPACE
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`CIVIL ACTION FILE #:
`
`State Court of Fulton County
`**E-FILED"
`22EV001384
`3/4/2022 2:31 PM
`Christopher G. Scott, Clerk
`Civil Division
`
`TYPE OF SUIT
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`AMOUNT OF SUIT
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`[ 1 ACCOUNT
`[ ICONTRACT
`[ ]NOTE
`[—FORT
`[ j PERSONAL INJURY
`[ ] FOREIGN JUDGMENT
`[ 1 TROVER
`[ I SPECIAL LIEN
`
`PRINCIPAL $
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`INTEREST $
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`ATTY. FEES $
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`COURT COST
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`-.11111n1.1111..
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`NEW FILING
`[ IRE-FILING: PREVIOUS CASE NO.
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`GEORGIA, FULTON COUNTY
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`STATE COURT OF FULTON COUNTY
`Civil Division
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`W. A. GRIFFIN, M.D.
`550 PEACHTREE STREET NE SUITE 1490
`ATLANTA GA 30308
`
`Plaintiffs Name, Address, City, State, Zip Code
`
`vs.
`*blue. Cro$S S1Lte-
`S3)4Y1
`e4
`o C%,a.pco_c&-C-11/41.r%
`OA\ qer 9ee \—
`Defendant's Name, Address, City, State, Zp Cnrfr
`LekW rerN cev't Nte_ (5,e_tle-s'ke-% 300
`SUMMONS
`
`TO THE ABOVE NAMED-DEFENDANT:
`You are hereby required to file with the Clerk of said court and to serve a copy on the Plaintiff's Attorney, or on Plaintiff if no Attorney, to-wit
`Name: W. A. GRIFFIN, MD
`Address: 550 PEACHTREE STREET NE SUITE 1490
` Phone No.:4045234223
`City, State, Zip Code: ATLANTA, GEORGIA 30308
`An answer to this complaint, which is herewith served upon you, must be filed within thirty (30)days after service, not counting the day of service. If you
`fail to do so, judgment by default will be taken against you for the relief demanded in the complaint, plus cost of this action. DEFENSES MAY BE MADE &
`JURY TRIAL DEMANDED, via electronic filing or, if desired, at the e-filing public access terminal in the Self-Help Center at 185 Central Ave., S.W.,
`Ground Floor, Room TG300, Atlanta, GA 30303.
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`Christopher G. Scott, Chief Clerk (electronic signature)
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`SERVICE INFORMATION:
`Served, this
`day of
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`, 20
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`WRITE VERDICT HERE:
`- We, the jury, find for
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`DEPUTY MARSHAL, STATE COURT OF FULTON COUNTY
`
`A
`
`This
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`day of
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`, 20 Foieperson
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`(STAPLE TO FRONT OF COMPLAINT)
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`1Page I of 21
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`State Court of Fulton County
`**E-FILED"
`22EV001384
`3/3/2022 4:49 PM
`Christopher G. Scott, Clerk
`Civil Division
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`FULTON STATE COURT
`
`W.A. GRIFFIN, MD
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`Plaintiff,
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`VS
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`BLUE CROSS BLUE SHIELD
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`HEALTHCARE PLAN OF GEORGIA, INC.
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`Defendant,
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`COMPLAINT
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`PRO SE
`550 Peachtree Street N.E.
`Suite 1490
`Atlanta, Georgia 30308
`(404) 523-4223 wagriffinerisa@hotmail.com
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`INTRODUCTION
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`PLAINTIFF W. A. Griffin, M.D. alleges against Defendant as follows:
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`I. JURISDICTION AND VENUE
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`1. This Court has subject matter jurisdiction over this action pursuant 28. U.S.C.
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`1 331, because the action arises under the laws of the United States, pursuant to 29
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`U.S.0 1332(e)(1), because claimant seeks to enforce rights under the EmploymentRetirement
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`I ncome Security Act ("ERISA"). This Court is the proper venue for this action pursuant to 28
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`U.S.C. 139I(a), because Defendant conduct business operations in this Judicial District.
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`I. THE PARTIES
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`A. PLAINTIFF
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`2.
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`W. A. Griffin, MD is a resident and medical provider in Fulton County, Georgia.
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`Plaintiff, as a condition of service, requires patients to assign his or her health insurance benefits
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`and rights. Plaintiff received an assignment of benefits and rights (emphasis added) for
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`every claim at issue in this litigation. Plaintiff has standing to pursue the claims for relief in
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`this Complaint as an assignee of the member's benefits and rights under the health plan and
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`rights under ERISA. Medical providers have derivative standing to sue under ERISA. Cagle
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`v. Bruner, 112 F.3d. 1510, 1515 (11 th Cir. 1997)
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`Page 13 of 21
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`B. BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
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`3.
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`Plaintiff is informed and believes that Defendant Blue Cross Blue Shield Healthcare
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`Plan of Georgia, Inc. is an ERISA plan fiduciary in its role as a "HostPlan" and/or "Home
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`Plan" based upon its contractual role in the Blue Card Program.'
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`4.
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`In some cases, the Host Plan is Blue Cross Blue Shield Healthcare Plan of
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`Georgia, Inc. Some participants in this case were seen outside of the Home Plan service area
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`and have services provided in Georgia. Blue Cross Blue Shield Healthcare Plan of Georgia,
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`Inc., in its role as the Host Plan, processes claims, accepts appeals, accepts medical records,
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`processes appeals, and sets the fee schedule for CPT codes in its geographic region and
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`communicates back and forth with the Home Plan with each provider claim and appeal that is
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`submitted in Georgia.
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`'The Blue Card program requires that provider claims, appeals, document request, and
`medical records are submitted to the local Host plan (See Provider Manual for the Blue Card
`Program httos://v.rwwl 1.anthem.com /prov ider/g,a/plansbenefits/nosecondarv/notel 1 iarv/pw
`g25 1 600.ndf?refer=ahmovider&state=ga)
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`Page 13 of 21
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`5. In other cases, Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. is the Home Plan.
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`This means that the company has a direct third party administrative (TPA) services agreement
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`with a self-funded Georgia based employer and/or is the plan administrator for its fully insured
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`plans within the state of Georgia. Blue Cross Blue Shield Healthcare Plan of Georgia, Inc., in
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`its role as the Home Plan, processes claims, accepts appeals, accepts medical records,
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`processes appeals, and sets the fee schedule for CPT codes in its geographic region and
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`communicates back and forth with each provider claim and appeal that is submitted in
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`Georgia.
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`6.
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`Upon information and belief, Blue Cross Blue Shield Healthcare Plan of Georgia has
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`assignments (emphasis added) through the multi-state Blue Card program that permit each Blues
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`"brother" entity to act on each other's behalf in a fiduciary capacity for ERISA claims, appeals,
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`and document request. The entire point of the program is to permit a single contact for all services
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`rendered within the State of Georgia. 2
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`20ther Blue Cross companies and/or named ERISA plan administrators may be added to this
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`lawsuit ifnecessary
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`7. Blue Cross and Blue Shield Healthcare Plan of Georgia (hereafter, "Blue Cross"), in its role
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`as a claims fiduciary through the Blue Card program and/or the local Home and/or Host plan, has
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`discretionary authority for the processing of claims, fee schedules, rate tables, methodology,
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`administrative appeals, and ERISA plan document request for every claim at issue in this
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`Complaint.
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`8.
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`Blue Cross can be served with process at its agent, CT Corporation System 289 Culver Street,
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`Lawrenceville, Georgia 30046.
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`III. Dr. Griffin's Assignment of Benefit and Rights and Communication with Blue
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`Cross During the Administrative Appeals
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`9. Dr. Griffin obtained a written assignment of benefit and rights in accordance with
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`Georgia § 33-24-54 for every member in this case. 3 If any of the ERISA plans at issue in the lawsuit
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`require a consent from the insurer or the plan in order to be valid, it was decided decades ago that
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`those provisions would not be enforceable in Georgia. "The assignments being perfectly valid
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`without the consent of the insurer, and its rights being in no way affected thereby, the condition in
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`question was superfluous, and the law will not tolerate its enforcement against the assignee." Georgia
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`Co-Op. Fire Assn. v. Borchardt & Co., 123 Ga. 181, 183-184 (51 SE 429) (1905)
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`3Georgia § 33-24-54. Payment of benefits under accident and sickness policies to licensed nonparticipating
`or nonpreferred providers ...whenever an ... or self-insured health benefit plan, by whatever name called,
`which is issued or administered by a person licensed under this title provides that any of its benefits are
`payable to a participating or preferred provider of health care services licensed under the provisions of ...
`for services rendered, the person licensed under this title shall be required to pay such benefits either directly
`to any similarly licensed nonparticipating or nonpreferred provider who has rendered such services, has a
`written assignment of benefits, and has caused written notice of such assignment to be given to the person
`licensed under this title or jointly to such nonparticipating or nonpreferred provider and to the insured,
`subscriber, or other covered person; provided, however, that in either case the person licensed under this
`title shall be required to send such benefit payments directly to the provider who has the written assignment.
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`Page 15 of 21
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`10. Likewise, if any of the ERISA plans at issue in this lawsuit have provider anti-assignment
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`provisions, those provisions are not pre-empted by ERISA regarding
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`Georgia § 33-24-54
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`assignment statute. Recently, the Supreme Court has now explicitly held that "ERISA does not
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`pre-empt state rate regulations that merely increase costs or alter incentives for ERISA plans
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`without forcing plans to adopt any particular scheme of substantive coverage." See Rutledge v.
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`Pharmaceutical Care Management Ass'n, 141 S.Ct. 474 (2020). This Court is bound by the
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`instructive precedent of Rutledge.
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`1 1. Every assignment of benefit at issue in the lawsuit minimally expressly states the following:
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`This is a direct assignment of my rights and benefits under this policy and designation of
`authorized representative
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`121 A photocopy of this Assignment shall be considered as effective and valid as the original.
`0 I hereby authorize the above named provider(s) to release all medical information
`necessary to process my claims under HIPPA to any insurance company, adjuster, or
`attorney involved in this case for the purpose of processing claims, claim appeals,
`grievances, and securing payment of benefits. I hereby authorize any plan administrator or
`fiduciary, insurer and my attorney to release to such provider(s) any and all plan
`documents, insurance policy and/or settlement information upon written request from such
`provider(s) in order to claim such medical benefits, reimbursement or any applicable
`remedies. I authorize the use of this signature on all my insurance and/or employee health
`benefits claim submissions
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`CI This assignment is valid for all administrative and judicial reviews under PPACA,
`ERISA4, Medicare, and applicable state laws.
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`4 See Conn. State Dental Ass 'n v. Anthem Health Plans, Inc., 591 F.3d 1337, 1347 (11th Cir.
`2009). Dr. Griffin is entitled to sue for all remedies under ERISA including statutory penalties.
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`Page 17 of 21
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`12. Relevant parts of every first and level appeal submitted to Blue Cross communicated the
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`following language:
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`ERISA claim regulation, ERISA § 2560.503-1(g), Manner and Content of Notification of
`BenefitDetermination, specifically requires the followings in part:
`"(i) The specific reason or reasons for the adverse determination;
`(ii) Reference to the specific plan provisions on which the determination is based;
`(iii) A description of any additional material or information necessary for the claimant to
`perfect the claim and an explanation of why such material or information is necessary;
`(iv) A description of the plan' s review procedures and the time limits applicable to
`such procedures, including a statement of the claimant's right to bring a civil action
`under section 502(a) of the Act following an adverse benefit determination on review;
`(v) In the case of an adverse benefit determination by a group health plan or a plan
`providing .disability benefits,
`(A) If an internal rule, guideline , protocol, or other similar criterion was relied upon
`in making the adverse determination, either the specific rule, guideline, protocol.
`or other similar criterion; or a statement that such a rule, guideline, protocol, or
`other similar criterion was relied upon in making the adverse determination and
`that a copy of such rule; guideline, protocol, or other criterion will be provided
`free ofcharge to the claimant upon request"
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`In order to determine if your calculation of reasonable and customary charges deviate from the
`Plan's written description of those calculations in any ways. We need to understand if you calculate
`reimbursement payments for the above captioned group insurance plans based upon a set percentile
`(e.g. the 85th or 90th percentile) of the entire range of charges for a given procedure in a geographic
`region, and if your practice is inconsistent with the "equal to the charge" and "does not exceed the
`usual charge" language that most insurers and ERISA plan payers use in each plan specific
`definition of "reasonable and customary." Second, we need to verify if you failed to calculate the
`"usual charge" for a given medical procedure by the "reasonable and customary" amount in a
`geographic area, instead you relied upon someone else plans definition, or fraudulent
`methodologies to provide such figures. We need also to determine if two different methodologies,
`formulas and fee schedules relied upon by you on initial benefits determination and subsequent
`retrospective adverse benefits determination are inadequate , and that when that is the case, multiple
`disparate geographic areas are grouped together in the process of calculating the "usual charge."
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`In order to enable the participant and beneficiary of this claim to both appreciate the fatal in
`adequacy of this claim as it stands and to gain a meaningful review by knowing with what to
`supplement the record, and in order to secure a meaningful participation of a full and fair review
`of the denied claims, we hereby specifically request from you, this plan administrator or
`appropriate name fiduciary, any copies of the plan documents under which this plan is operated
`and upon which the above captioned claim denial is based, procedures, formulas , methodologies ,
`guidelines, schedules, protocols, and other guidelines; all documents which the plan reviewed or
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`could have reviewed in denying this claim; consultant or service provider reports and the entire
`claim file pertinent to this claim denial, including but not limited to "if that information affects
`beneficiaries' material interests "(U.S. Supreme Court. Pegram et al. v. Herdrich):
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`contained in a document designated as the "plan document". Accordingly, studies, schedules or
`similar documents that contain information and data, such as information and data relating to
`standard charges or calculating a participant's or beneficiary's benefit entitlements under an
`employee benefit plan would constitute "instrument under which the plan is... operated."
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`Please refer to DOL Advisory Opinions, 96-14A & 97-1 IA, in support of such interpretation of
`"plan document" and this ,SPFCIFTC EO
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`Also enclosed is a copy of SPD request in accordance with ERISA § 502 (c); 29 USC§ 1 132 (c)
`& ERISA § 511; 29 USC § 1 141.
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`This appeal is filed with the Plan Administrator of the above captioned plan, or appropriate named
`fiduciary or insurer of the plan. Any individual who is not designated as plan administrator or
`appropriate named fiduciary by this plan is required, by ERISA and as your fiduciary duty, to
`forward this legal document to such appropriate individual.
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`We also note that section 404(a)(1 )(D) of ERISA requires a fiduciary to discharge his duties in
`accordance with the documents and instruments governing the plan insofar as they are consistent
`with the provisions of Title I of ERISA. Therefore, in addition to the above section 104(b)(4)
`obligations, if such a plan document or instrument, consistent with the other provisions of Title
`requires the furnishing or disclosure of information to a participant or beneficiary on request, the
`administrator would be required to grant such a request." DOL Advisory Opinion, 97-1 1 A, ERISA,
`SECS. 104(b)(2) and 104(h)(4).
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`Should this ERISA plan contains unambiguous anti-assignment clause prohibiting assignment of
`rights, benefits and causes of action in SPD, the plan administrator is required to timely notify or
`disclose to the assignee of such prohibition by disclosing such SPD, especially on this appeal
`process, to avoid judicial unenforceability of your anti-assignment clause on judicial process.
`(Hermann Hasp. v. MEBA Medical and Benefits Plan)
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`"We do not think Congress' purpose in enacting the ERISA disclosure provisions - ensuring that
`"the individual participant knows exactly where he stands with respect to the plan," H. R. Rep.-No.
`93-533, p. 11(1973) - will be thwarted by a natural reading of the term "participant." Faced with the
`possibility of $110 a day in penalties under I 132(c)( l)( B), a rational plan administrator or fiduciary
`would likely opt to provide a claimant with the information requested if there is any doubt as to whether
`the claimant is a "participant," especially when the reasonable costs of producing the information
`can be recovered. See 29 CFR 2520.104b-30(b) (1987) "(U.S. Supreme Court. FIRESTONE TIRE&
`RUBBER CO. v. BRUCH, 489 U.S. 101 (1989))
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`Please comply with such request within 30 days of this written request. Your failure to comply
`with such plan document request may result in a penalty up to $110.00 per day.
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`A copy of legal assignment of benefits from the participant of this plan under ERISA. is enclosed to satisfy ERISA
`legal and derivative standing requirements.
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`1 3. Dr. Griffin meticulously communicated with Blue Cross that she had obtained a written assignment of benefits and
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`rights, aggressively filed ERISA claims, appeals, and document request via certified mail, and constantly warned Blue
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`Cross that it had the fiduciary to administer the appeal and/or comply with plan document requests or it would be
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`subjected to $100 per day penalty claim.
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`1.4. Blue Cross exclusively responded to Dr. Griffin during the claim submissions and administrative appeals and it
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`accepted all the ERISA plan document request.
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`1 5. Blue Cross, the named IERISA plan administrators, the plan sponsors and the Blue Card program mandate that
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`every claim submission, document request, and appeal is filed with the local Blue Cross plan.
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`16. In every matter in this case,.Blue Cross handled every claim, document requests, and administrative appeals. No
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`other Blue Cross entity outside of Georgia engaged with Dr. Griffin or responded directly to administrative appeals.
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`Every claim related matter and/or administrative appeal related matter had the local Georgia Blue Cross logo on the
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`communication to Dr. Griffin.
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`l 7. Blue Cross is the delegated fiduciary with discretionary authority for the administrative appeals and document
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`request through its local contracts as the Home plan. Blue Cross is a de facto plan administrator in its capacity as "an
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`ERISA fiduciary administering, managing and controlling" the health benefit plans pursuant to the authority given by
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`the plan sponsors. The Eleventh Circuit recognizes a de facto plan administrator category. Rosen v. TRW, Inc., 979
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`F.2d 191, 193-94 (11th Cir. 1992) ("[W]e hold that if a company is administrating the plan , then it can be held liable
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`for ERISA violations, regardless of the provisions of the plan documenl..").
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`1 8. Blue Cross is the delegated fiduciary, through its assignment, with discretionary authority for the administrative
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`appeals and document request submitted to it through the Blue Card program. Blue Cross is the Blue Card de facto plan
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`administrator in its capacity as "an ERISA fiduciary administering, managing and controlling" the health benefit plans
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`pursuant to the authority given by the Plan sponsors. The Eleventh Circuit recognizes a de facto plan administrator
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`category. Rosen v. TRW, Inc., 979 F.2d 191, 193-94 (11th Cir. 1992) ("[Me hold that if a company is administrating
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`the plan , then it can be held liable for ERISA violations, regardless of the provisions of the plan document.").
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`Facts
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`1 9.
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`Patient V.H. (plan sponsored by General Electric Company) presented to Plaintiff for
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`medical services on June 14,2013 for two surgical procedures. A phone call was made to Blue
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`Cross to confirm that the "out of network benefits" were payable at the " usual customary and
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`reasonable benefit levels." (Hereafter UCR) (Reference #201316508826 - Plaintiff spoke with
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`"Stan", a Blue Cross customer service representative, at 12:37 p.m., eastern standard time).
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`The claim associated with this patient was mailed Certified Particle No. 7012 3050 00020475
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`3030.
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`20. The billed amount totaled $5,538.08. BCBS allowed only $1,735, and the provider
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`received apayment totaling $1,605.69. The amount owed to the provider/Plaintiff is
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`$3, 802.57. The explanation of benefits revealed extreme UCR cheating and did not
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`offer an explanation.
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`21.
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`On August 18, 2013, a level one appeal was sent to BCBS by Certified Particle No. 7012
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`3050 0002 0475 4044 that included a request for a full and fair review, a copy of the
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`summary plan description (pursuant to 29 U.S.C. Section 1022), publications, database
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`and schedules used to determine the usual customary and reasonable benefits, contact
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`information for the plan administrator, and a summary plan description request form, and
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`a copy of the administrative service agreement.
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`22.
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`Following submission of the level one appeal, Plaintiff received a letter dated October 9,
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`2013, which denied the appeal, did not offer a full and fair review of the claim, nor did it
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`include a summary plan description. Further, it offered a totally inadequate explanation for
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`the denial andmade an inaccurate reference to one of the billed codes, stating it was
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`"investigational" and
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`"per appeal review decision, the denial stands," leaving the Plaintiff to conclude that the
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`individual responsible for the letter did not receive appropriate ERISA appeal training. None
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`of the requested forms, as required by ERISA (29 U.S.C. 1022) were sent to Plaintiff.
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`23. On October 15, 2013, a level two appeal was sent to BCBSGA and included a SECOND
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`REQUEST for the summary plan description and publication, rate tables, and schedules used to
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`determine the usual customary and reasonable benefit levels, and contact information for the plan
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`administrator. The appeal was received on October 17, 2013.
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`24.
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`On November 29, 2013 the Plaintiff received a letter dated November 25, 2013 that stated
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`"we do not show receiving a claim under this identification number".
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`25.
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`On December 2, 2013 the Plaintiff faxed a letter to inform BCBS that the memo dated
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`November 25, 2013 was out of context in that claim already processed and that level one and
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`level two ERJSA appeals had been filed.
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`26.
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`On February 3,2014 Plaintiff received a letter dated January 27, 2014 and a second letter
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`dated January 28, 2014 from BCBS. The first letter stated that "in order to have a second
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`appeal review, your letter must state this is your second level of appeal." In the second letter,
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`it stated that the original claim determination would be upheld and that the appeal would be
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`sent to Blue Cross and Blue Shield of Alabama. This case is a prime example of bad faith
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`on the part of Defendant BCBS. All the numerous misguided, irrelevant denial letters
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`had nothing to do with a full and fair review. To date, the provider is owed$ 3,802.57 for
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`this claim and the discretionary penalties.
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`27.
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`Patient V.H. presented to the Plaintiff again on June 21, 2013 for minor
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`surgical procedure. The billed amount totaled of $2973.06 and Defendants
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`BCBS only allowed $1150.27 when the claim was processed on August 9,2013.
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`28.
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`August 21, 2013, a level one appeal was sent Certified Particle No. 7012 3050 0002
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`0475 0060 to request a full and fair review and included request for summary plan
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`description, contact information for the plan administrator, a copy of the current contract,
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`and publications, databases schedules used to dete I mine the usual, customary, and
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`reasonable charges for the plan. However , the appeal was never answered even though
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`BCBS received it on August 28, 2013.
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`29.
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`On February 3,2014 level two appeal was sent Certified Particle No. 7023 0500 0020 47522242
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`to Blue Cross of Georgia to express Plaintiffs concern of the lack of response to the level
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`one appeal and requested documents. A second request for plan documents was included in
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`Plaintiffs correspondence. BCBS received the appeal on February 6, 2014. However, a
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`response was never received from the Defendants BCBS. To date, the additional amount owed
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`for the claim is totaled $1822.79 and discretionary penalties.
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`30.
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`Patient V.H.. presented to Plaintiff again on October 18, 2013 and had services rendered
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`that totaled of $3915. Blue Cross only allowed $82 I .42 (or 20% of the billed charges) paid to
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`the provider. The claim was processed on December 3, 2013 and the level one appeal was sent
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`by Certified Particle No. 7012 3050 0002 0475 1500 which included a fifth request for the
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`summary plan description, a copy of the current contract, contact information for the plan
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`administrator, publications, database, and schedules used to determine the UCR.
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`31.
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`On February 10, 2014 the Plaintiff received a denial letter dated February 6,2014 which
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`lackedany pertinent information regarding a full and fair review. Said letter contained a two
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`sentence response that stated "the appeal has been denied. The client processed correctly
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`per group benefits."
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`32.
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`Plaintiff alleges all the appeals for patient V.H. have been performed in a negligent manner.
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`33.
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`As a final attempt to get patient V.1-I. a full and fair review, on February 3, 2014 a level two
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`appeal was sent Certified Particle No. 7012 3050 0002 0475 2200 and included a sixth
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`request for the summary plan description, contact information for the plan
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`administrator, and publication, database, and schedules used to determine the usual
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`customary and reasonable charges. To date the level two appeal has not been answered
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`and none of the requested documents have been received. The provider is owed an
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`additional amount of $3093.58 and discretionary penalties.
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`34.
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`Despite meticulous, certified appeals and document request NONE of the requested documents
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`were received.
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`35.
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`Patient B.A. (plan sponsored by Publix Super Markets, Inc.) presented to Plaintiff for
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`medically necessary surgery services on June 25, 2014. Plaintiffs office staff verified benefits
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`using 800 number on the back of the I.D. card to verify coverage for out of network benefits.
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`The claim file was mailed via Certified Particle No. 7014 0150 0000 2435 6301 and included
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`a written legal assignment of benefit form/designated authorized representative form, and a
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`Blue Cross specific designated authorized representative form.
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`36.
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`The UCR charges totaled $12, 672.88. Blue Cross and Blue Shield of Georgia received the
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`claim file on June 27, 2015.
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`37.
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`Six months passed and the member's claim was not processed. Therefore, on December
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`19, 2014, Plaintiff sent a letter to Blue Cross via Certified Particle No. 7014 0150 0000 2435 8404.
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`The letter strongly urged Blue Cross to process the claim or Plaintiff would sue.
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`38.
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`On January 29, 2015 Plaintiff called Blue Cross to check the status of the claim and was
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`advised that "claim will be sent to claims department and processed in thirty
`days"(reference#02150290220000, spoke with Lakeeta a 11:10 A.M.).
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`39.
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`On February 17, 2015 Plaintiff called Blue Cross to check the claim status again and was
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`advised "claim sent for processing on January 29, 2015" (reference #02150470948200).
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`40.
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`On March 2,2015 Plaintiff called Blue Cross a third time to check the status of the claim
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`and was advised that" the claim is in adjustment status.
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`1 will request escalation. Give it
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`another 10 to 14 days" (reference #02150610387300, spoke with Virginia at 10:38 A.M.).
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`41.
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`Finally, on March 16, 2015 Blue Cross processed the claim and did not obey the Georgia
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`law mandatory assignment of benefit statue that requires payment be mailed directly to the provider
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`(See Georgia § 33-24-54).
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`42.
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`Patient B.A. was mailed a check for $438.00 (which was turned over to the provider). Blue
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`Cross did not honor the UCR fee schedule and paid the employee claim to the equivalent of a
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`state Medicaid beneficiary, not private insurance. The provider is owed an additional payment
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`of $9, 562.88.
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`43.
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`On March 13, 2015 Plaintiff mailed a First Level Appeal to Blue Cross via Certified Particle
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`No. 7014 0150 0000 2435 9807. The appeal included document requests in additional to a full
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`and fair review.
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`44. Plaintiff did not hear a peep from Blue Cross. The First Level Appeal was ignored and NONE of
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`the requested plan documents were receive.
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`45. Patient R.N (plan sponsored by Publix Super Markets, Inc.) presented to Plaintiff on
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`September 6, 2013 for medical services. The claim was mailed via Certified Particle No. 7012
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`3050 0002 0475 0374 with a copy of the written assignment of benefit. The claim totaled
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`$1924.02 based upon the UCR for the geographic area.
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`16. Blue Cross processed the claim and ignored the member's direct payment request to the
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`provider. The member was paid $301.00 and the check was turned over to the provider. An
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`additional benefit payment of $492.00 is owed to the provider. Blue Cross low-balled the claim
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`by not honoring the UCR fee schedule for the plan allowable.
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`47. In good faith, Plaintiff submitted a First Level Appeal dated 11-28-2013 via Certified
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`Particle No. 7012 3050 0002 0475 1883 and received by Blue Cross on December 2, 2013. The
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`appeal letter requested a full and fair review including several document requests.
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`48. On January 29, 2014 Plaintiff received a letter from Blue Cross dated January 25, 2014. The
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`contents stated as follows:
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`This claim processed with the patient home plan directly. They allowed $1 101.84. $301.00
`was paid. Please contact Home plan directly for complete details.
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`49. The three-liner response was Blue Cross' version of a full and fair review. None of the requested
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`plan documents were received.
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`50. On March 13, 2014, Plaintiff received a letter dated March 10, 2014 from BCBS that gave
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`generic, blanket denial that did not meet the criteria for a full and fair review. There was no mention
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`of the requested plan documents. It was clear that Blue Cross was not qualified to execute ER1SA
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`full and fair review requirements.
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`51. Patient M.F.( plan sponsored by Publix Super Markets, Inc) presented for medical services on
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`April 25, 2013. The total UCR charges totaled $3, 346.54. The claim was submitted to Blue Cross
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`along with a copy of the written assignment of benefit. The claim processed and Blue Cross only
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`allowed 20 percent of the charges. The member was sent a check for $86.41 even though Blue
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`Cross was instructed to mail the provider the payment. The provider is owed an additional payment
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`totaled $ 1, 561. 74.
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`52. Plaintiff submitted a First Level Appeal and a Second Level Appeal with document request to
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`to Blue Cross via Certified Particle; However, a full and fair review was never honored. Blue
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`Cross sent a scant -generic responses similar to patient R.N. No documents were turned over.
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`53.
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`On September 29, 2014 patient A.G.( plan sponsored by Publix Super Markets, Inc.)
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`presented to Plaintiff's office surgical services. The total UCR charges totaled $7, 682.00. The claim
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`was sent via Certified Particle No. 7014 0150 0000 2435 7438 and received October 3, 2014 by Blue
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`Cross.
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`54.
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`On March 2,2015 Plaintiff called Blue Cross at 1800-628-3988 to check the claim status.
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`Plaintiff was advised that BCBS processed the claim and a check for $723.33 was mailed to the
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`member.
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`55. Blue Cross violated Georgia State mandatory assignment of benefit statue § 33-24-54 and did
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`not honor the member's request that payment be mailed directly to the provider. (Reference #
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`02150610193700 3/3/2015).
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`After contacting the member several times, Plaintiff never
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`received the check. Additionally, patient A.G. stated that she never received the payment. It is
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`assumed that the check was lost in the mail. Nevertheless, Plaintiff is owed $4, 957.40.
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`•56. On March 2, 2015 Plaintiff submitted a First Level Appeal to Blue Cross. The appeal was sent
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`via Certified Particle No. 7014 0150 0000 2435 9739. The appeal included plan document
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`requests including SPD, a copy of the written assignment of benefit, and a copy of the Blue
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`Cross specific authorized representative consent.
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`57. Plaintiff did not hear a peep from Blue Cross. The First Level Appeal was ignored and NONE
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`of the requested plan documents were received.
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`58: On December 23, 201