Warning Letter Summary Report - June 2025 |
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| Contract ID(s) and Names | Parent Organization Name | Organization Contact Name | Organization Contact Phone | Compliance Issue ID | Date Letter Sent | Issue Type | Issue Topic | Issue Summary | Letter Name |
|---|---|---|---|---|---|---|---|---|---|
|
H3917 - PITTSBURGH CARE PARTNERSHIP, INC. |
UPMC Health System | STACI KACZKOWSKI | 4124361338 | 86428 | 30-MAY-2025 | Drug Benefit | OMS | Failure to submit Overutilization Monitoring System report form by deadline | Warning Letter.pdf |
|
H9576 - NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND |
NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND | Lisa Carcieri | 4014596008 | 86268 | 29-APR-2025 | Health Benefit | Appeals and Grievances, Including Coverage/Organization Determination | NHPRI did not identify oral grievances, nor appropriately report these grievances in alignment with demonstration reporting requirements. | 86268_0_05192025120324576_NHPRI Warning Letter 4.29.25.pdf |
|
H9047 - PROVIDENCE HEALTH ASSURANCE |
Providence St Joseph Health | Misty Dunphy | 5035746608 | 85670 | 25-MAR-2025 | Health and Drug Benefit | Enrollment | One delinquent download for CY 2025 on February 25, 2025. This is the second incident within a years time. | Warning Letter.pdf |
|
H3917 - PITTSBURGH CARE PARTNERSHIP, INC. |
UPMC Health System | STACI KACZKOWSKI | 4124361338 | 85668 | 25-FEB-2025 | Drug Benefit | OMS | Failure to submit Overutilization Monitoring System report form by deadline | Warning Letter.pdf |
|
H3810 - ALLCARE HEALTH PLAN, INC. |
AllCare Health, Inc. | Nicole LaFond | 8884600185 | 85529 | 21-FEB-2025 | Health Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H3810 - ALLCARE HEALTH PLAN, INC. |
AllCare Health, Inc. | Nicole LaFond | 8884600185 | 85583 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H4091 - SIMPRA ADVANTAGE, INC. |
Associated Care Ventures, Inc. | Member Services | 8446374770 | 85536 | 21-FEB-2025 | Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H4091 - SIMPRA ADVANTAGE, INC. |
Associated Care Ventures, Inc. | Member Services | 8446374770 | 85578 | 21-FEB-2025 | Health Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H0982 - SOLIS HEALTH PLANS, INC. |
Athena Healthcare Holdings, LLC | Provider Services | 8336159259 | 85580 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H0302 - MEDISUN, INC. |
Blue Cross Blue Shield of Arizona | Member Services | 4809370409 | 85636 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H5140 - BLUE CROSS AND BLUE SHIELD ARIZONA, INC. |
Blue Cross Blue Shield of Arizona | Member Services | 4809370409 | 85644 * | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H3449 - BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA |
Blue Cross and Blue Shield of North Carolina | Member Services | 8882969790 | 85641 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H7813 - ICIRCLE SERVICES OF THE FINGER LAKES, INC. |
CDS Monarch, Inc. | Becky Ortiz | 8444247253 | 85650 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H6170 - CHAMPION HEALTH PLAN OF CALIFORNIA INC |
Champion Health Plans-USA, LLC. | Mechelle Reed | 8008858000 | 85634 | 21-FEB-2025 | Health Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H0876 - Commonwealth Care Alliance Rhode Island, LLC |
Commonwealth Care Alliance, Inc. | Member Services | 8664209332 | 85637 * | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H9876 - Commonwealth Care Alliance Rhode Island, LLC |
Commonwealth Care Alliance, Inc. | Member Services | 8334209332 | 85654 * | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H2034 - COMMUNITY CARE HEALTH PLAN, INC. |
Community Care, Inc. | Provider Hotline | 8669372783 | 85531 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H2034 - COMMUNITY CARE HEALTH PLAN, INC. |
Community Care, Inc. | Provider Hotline | 8669372783 | 85581 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H5826 - COMMUNITY HEALTH PLAN OF WASHINGTON |
Community Health Plan of Washington | Customer Care | 8009420247 | 85645 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H1977 - UPPER PENINSULA HEALTH PLAN, LLC |
DLP Marquette General Hospital, LLC | Nicole Stewart | 9062251177 | 85530 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H7220 - HealthKeepers, Inc. |
Elevance Health, Inc. | Nina Barrow | 8004559776 | 85649 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H1280 - ETERNALHEALTH, INC. |
Eternal Health of Delaware, Inc. | Provider Services | 8006809255 | 85655 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H2694 - ETERNALHEALTH, INC. |
Eternal Health of Delaware, Inc. | Provider Services | 8006809255 | 85656 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H3551 - ETERNALHEALTH OF ARIZONA INC |
Eternal Health of Delaware, Inc. | Provider Services | 8006809255 | 85658 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H4869 - GOLD KIDNEY OF ARIZONA |
Gold Kidney Health Plan | Francisco Leon | 8442946535 | 85535 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H7598 - GROUP HEALTH COOPERATIVE OF EAU CLAIRE |
Group Health Cooperative of Eau Claire | Adam Yang | 7158522984 | 85635 | 21-FEB-2025 | Health Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H8894 - Inland Empire Health Plan |
INLAND EMPIRE HEALTH PLAN | Member Services | 8772734347 | 85585 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H1994 - SELECTHEALTH, INC. |
Intermountain Health Care, Inc. | Kaleb Holt | 8014427954 | 85639 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H2246 - SELECTHEALTH, INC. |
Intermountain Health Care, Inc. | Kaleb Holt | 8014427954 | 85640 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H3305 - MVP HEALTH PLAN, INC. |
MVP Health Care, Inc. | Richard Santilli | 5189913775 | 85633 | 21-FEB-2025 | Health Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H5211 - SECURITY HEALTH PLAN OF WISCONSIN, INC. |
Marshfield Clinic Health System, Inc. | Sara Foemmel | 7152219950 | 85659 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H7115 - MEMORIAL HERMANN HEALTH PLAN |
Memorial Hermann Health System | Jay Hurt | 7135972523 | 85648 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H6765 - AMERICAN HEALTH PLAN OF IOWA INC |
Mitchell Family Office | Angie Brimm | 8663270523 | 85579 | 21-FEB-2025 | Health Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H3419 - PERENNIAL ADVANTAGE OF COLORADO, INC. |
Perennial Consortium, LLC | Rocio Sidlinger | 8558550489 | 85607 | 21-FEB-2025 | Drug Benefit | Accuracy & Accessibility Study | 2024 ACC WL | Warning Letter.pdf |
|
H8797 - PERENNIAL ADVANTAGE OF OHIO, INC. |
Perennial Consortium, LLC | Rocio Sidlinger | 8558550489 | 85608 | 21-FEB-2025 | Drug Benefit | Accuracy & Accessibility Study | 2024 ACC WL | Warning Letter.pdf |
|
H4045 - SANTA CLARA COUNTY HEALTH AUTHORITY |
SANTA CLARA COUNTY HEALTH AUTHORITY | Customer Services | 8777234795 | 85533 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H3727 - OH CHS SNP INC. |
SNP Holdings, LLC | Laura Risher | 8559695861 | 85582 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H9153 - WEST VIRGINIA SENIOR ADVANTAGE, INC. |
SNP Holdings, LLC | Laura Risher | 8448546888 | 85586 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H3811 - SAMARITAN HEALTH PLANS, INC. |
Samaritan Health Services, Inc. | Janice Crayk | 5417685192 | 85532 | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H3186 - SANFORD HEALTH PLAN OF MINNESOTA |
Sanford Health | Aleesa Jansick | 6053287182 | 85657 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H8385 - SANFORD HEALTH PLAN |
Sanford Health | Aleesa Jansick | 6053287182 | 85660 | 21-FEB-2025 | Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H4863 - TRH HEALTH INSURANCE COMPANY |
Tennessee Rural Health Improvement Association | Tracy Ring | 8339990135 | 85534 * | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
H4863 - TRH HEALTH INSURANCE COMPANY |
Tennessee Rural Health Improvement Association | Tracy Ring | 8339990135 | 85584 * | 21-FEB-2025 | Health and Drug Benefit | Accuracy & Accessibility Study | 2024 TTY WL | Warning Letter.pdf |
|
H1846 - MOUNT CARMEL HEALTH INSURANCE COMPANY |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85638 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H3668 - MOUNT CARMEL HEALTH PLAN, INC. |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85642 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H3828 - MOUNT CARMEL HEALTH PLAN OF IDAHO, INC. |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85643 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H6408 - MOUNT CARMEL HEALTH PLAN OF CONNECTICUT INC |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85646 * | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H6910 - MOUNT CARMEL HEALTH PLAN OF IDAHO, INC. |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85647 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H8998 - MOUNT CARMEL HEALTH PLAN OF CONNECTICUT INC |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85651 * | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H9179 - TRINITY HEALTH PLAN OF MICHIGAN INC |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85652 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H9827 - MOUNT CARMEL HEALTH PLAN OF NEW YORK, INC. |
Trinity Health Corporation | Patricia Suffern | 4124780244 | 85653 | 21-FEB-2025 | Health and Drug Benefit | Timeliness Study | 2024 CCM SI Q2 WL | Warning Letter.pdf |
|
H9066 - VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK |
VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | Amanda Frederick | 8884774663 | 85537 | 21-FEB-2025 | Drug Benefit | Accuracy & Accessibility Study | LEP 2024 WL | Warning Letter.pdf |
|
S5953 - BLUECROSS AND BLUESHIELD OF SOUTH CAROLINA |
BlueCross BlueShield of South Carolina (BCBSSC) | Provider Services | 8003342583 | 85239 | 17-JAN-2025 | Drug Benefit | Bid Submission | Failure to Submit CY 2025 Crosswalk by Bid Deadline | Warning Letter.pdf |
|
H2225 - COMMONWEALTH CARE ALLIANCE, INC. |
Commonwealth Care Alliance, Inc. | Member Services | 8664209332 | 81331 | 17-JAN-2025 | Health and Drug Benefit | Disenrollment | Commonwealth Care Alliance (CCA) Failure to Follow DSNP Deeming and Continued Eligibility Criteria, Provide Members with Notification of the Potential Disenrollment due to Loss of Special Needs Status, and Written Involuntary Disenrollment Notice: On February 15, 2024 CCA's compliance officer and interim enrollment manager notified their CMS AM that they had not followed the DSNP eligibility criteria for 163 members in contract H2225. The plan was notified by the state that the members were losing Medicaid eligibility but were eligible for Medicare Savings Programs. The plan stated that they erroneously filtered a spreadsheet and these members Medicaid statusus were not recognized to have entered deemed continued eligibility status. CCA should have sent members a deeming continued eligibility notice outlining next steps for members and allowing the one month Massachusetts deeming period. Instead, CCA continued enrollment for these members for varying lengths of time until the issue was discovered on January 22, 2024. Once discovered the plan terminated the 163 members with disenrollment dates of January 31, 2024 and sent incorrect voluntary disenrollment notification letters instead of the required involuntary disenrollment notification. CCA also disclosed they submitted the disenrollment transactions to CMS before or the member notifications had been sent. CCA states they have updated their reports and processes to accurately capture deeming members going forward and they will use the correct CMS required member notifications to guide members through this process. | Warning Letter.pdf |
|
H2624 - CARE N' CARE INSURANCE COMPANY OF NORTH CAROLINA |
HTA Holdings, LLC | Customer Service | 8889651965 | 85237 | 17-JAN-2025 | Drug Benefit | Bid Submission | Failure to Comply with CMS CY 2025 Bid Instructions | Warning Letter.pdf |
|
H9808 - CARE N' CARE INSURANCE COMPANY OF NORTH CAROLINA |
HTA Holdings, LLC | Customer Service | 8889651965 | 85238 | 17-JAN-2025 | Drug Benefit | Bid Submission | Failure to Comply with CMS CY 2025 Bid Instructions | Warning Letter.pdf |
|
H5433 - ORANGE COUNTY HEALTH AUTHORITY |
Orange County Health Authority | Customer Service | 8774122734 | 85235 | 17-JAN-2025 | Drug Benefit | Bid Submission | Failure to Comply with CMS CY 2025 Bid Instructions | Warning Letter.pdf |
|
H3204 - PRESBYTERIAN HEALTH PLAN |
Presbyterian Healthcare Services | PCSC Provider Care Unit | 5059235757 | 84822 | 17-JAN-2025 | Drug Benefit | Formulary Submission and Administration | Failure to Meet CY 2025 Formulary Requirements | Warning Letter.pdf |
|
H0137 - COMMONWEALTH CARE ALLIANCE, INC. H0876 - Commonwealth Care Alliance Rhode Island, LLC H2225 - COMMONWEALTH CARE ALLIANCE, INC. H9414 - Commonwealth Care Alliance Massachusetts, LLC. H9876 - Commonwealth Care Alliance Rhode Island, LLC |
Commonwealth Care Alliance, Inc. | Member Services | 8334209332, 8664209332 | 80901 | 16-JAN-2025 | Drug Benefit | PDE |
Commonwealth Care Alliance (CCA) Payment of Pharmacy Claims for Disenrolled Members and PDE Backlog: On February 15, 2024 CCA's compliance officer disclosed that the plan has erroneously been paying pharmacy claims for 291 disenrolled beneficiaries from 2/25/23 to present in Mass and RI MAPD contracts H9414, H2225, H9876, H0876 and the Mass MMP contract H0137. Of these 291 affected beneficiaries the plan estimates 100 benes are high pharmacy claims utilizers. The issue was disclosed when the account management team inquired about the progress of Plan-to-Plan claims remediation related to a disenrollment issue IMR #78717 and 1-800-MEDICARE complaints filed by benes. The plan told the AM that this issue occurred when they implemented a full file transfer to their PBM to resolve a data issue with an incremental file which was causing inaccurate LIS assignments and mis calculations of cost share IMR #78514. CCA did not consider the enrollment changes that occurred between 2/24-4/18/24 would not be captured in the plan's communications to the PBM after the temporary full file fix was stopped and a long-term fix was implemented. The PBM did not receive member disenrollment records, to match CCA's enrollment systems and MARx. CCA's compliance team stated the issue was prolonged when leadership did not take steps to resolve the issue and the enrollment staff were not were not working PDE rejections which has resulted in a backlog. Enrollment staff acknowledged they know how to process PDE rejections, but their workloads did not allow time for them to correct the discrepancies. CCA compliance was unable to tell the AM team how far back the PDE rejections backlog spans. The issue continues to unfold, and the plan will provide additional information as they uncover impact. The plan verbalized they will continue to pay pharmacy claims for these members but needs guidance from CMS to remediate this issue. |
Warning Letter.pdf |
|
H0342 - CAREPARTNERS OF CONNECTICUT, INC. H2256 - TUFTS ASSOCIATED HEALTH MAINTENANCE ORGANIZATION H5273 - CAREPARTNERS OF CONNECTICUT, INC. H6750 - HARVARD PILGRIM HEALTH CARE OF NEW ENGLAND, INC. H8330 - TUFTS ASSOCIATED HEALTH MAINTENANCE ORGANIZATION H9907 - TUFTS ASSOCIATED HEALTH MAINTENANCE ORGANIZATION S0655 - TUFTS INSURANCE COMPANY |
Point32Health, Inc. | Kenneth Kayser | 7816121000 | 79482 | 13-JAN-2025 | Health and Drug Benefit | Appeals and Grievances, Including Coverage/Organization Determination | Untimely resolution of Part C & D Grievances for Tufts Health plans and Harvard Pilgrim Health Care between December 2022 - July 2023 for contracts H2256, H9907, S0655, H5273, H0342, H8830, and H6750. | Warning Letter.pdf |
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H7813 - ICIRCLE SERVICES OF THE FINGER LAKES, INC. |
CDS Monarch, Inc. | Becky Ortiz | 8444247253 | 84682 | 03-JAN-2025 | Drug Benefit | Transition Policy | Failure to Submit CY 2025 Transition Policy by Deadline | Warning Letter.pdf |
|
H0876 - Commonwealth Care Alliance Rhode Island, LLC H9414 - Commonwealth Care Alliance Massachusetts, LLC. H9876 - Commonwealth Care Alliance Rhode Island, LLC |
Commonwealth Care Alliance, Inc. | Member Services | 8334209332, 8664209332 | 78473 * | 01-NOV-2024 | Health Benefit | Claims Processing | Commonwealth Care Alliance (CCA) Inaccurate Coinsurance Charges On May 18th, 2023, CCA notified their account manager that 253 members were charged an incorrect cost-share amount due to the incorrect configuration of 135 procedure codes by their claim vendor, PCG. The issue was identified when a member complaint was filed through 1-800-MEDICARE and the plan identified that additional claims were inaccurately configured. CCA will reprocess and adjust 595 impacted claims and will review all procedures codes with coinsurance to confirm they are correct. In instances where the cost-share was overapplied, CCA will reimburse the provider and the provider will be asked to reimburse the member. AM will follow-up to ensure members are reimbursed timely. The plan indicated they do not plan to seek reimbursement in cases where the cost-share was underapplied. The AM informed CCA that they must make at least one attempt to seek reimbursement. CCA will contact members to determine if any member was billed by providers inaccurate coinsurance and CCA will repossess claims submitted by providers correctly. Additionally, the plan will continue to review all codes with coinsurance to confirm if they are correct. The AM will provide updates on this issue as they unfold. | Warning Letter.pdf |
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H0302 - MEDISUN, INC. H5140 - BLUE CROSS AND BLUE SHIELD ARIZONA, INC. S6506 - BLUE CROSS AND BLUE SHIELD ARIZONA, INC. |
Blue Cross Blue Shield of Arizona | Member Services | 4809370409 | 82677 | 24-OCT-2024 | Drug Benefit | Drug Pricing | Blue Cross Blue Shield of Arizona-Drug Pricing Errors: On July 23, 2024, Blue Cross Blue Shield of Arizona (BCBS AZ) notified its CMS Account Manager that 3,810 enrollees were overcharged for prescription drugs between June 3, 2024 to June 18, 2024 at CVS, Walgreens, and Walmart pharmacies. BCBS AZ discovered the incorrect pricing issue after two complaints were filed on June 12, 2024 regarding a significant increase in prescription costs. On June 18, 2024, BCBS AZ alerted its Prescription Benefits Manager (PBM), OptumRx, of the potential issue and OptumRx immediately corrected the pricing issue. Additionally, OptumRx notified BCSB AZ on June 20, 2024 that the root cause was OptumRx's failure to include the maximum allowable cost (MAC) list pricing in its Performance network system. When a price change was submitted for CVS, Walgreens and Walmart effective June 3, 2024, the prices defaulted to average wholesale price, usual and customary price or submitted price rather than the MAC pricing for some generic drugs. OptumRx will take the following steps to remedy the issue with an expected August 1, 2024 completion date: outreach to impacted enrollees by phone, reverse and reprocess all impacted claims, and issue refunds for overpayment. Additionally, OptumRx will improve its audit tool for the quality review to ensure accurate pricing. AM is waiting for additional information including how the 708 providers were impacted and completion date of all corrective actions. (Account Manager: Yolanda Li, Division Director: Deanna Gee) | Warning Letter.pdf |
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S7126 - OMAHA HEALTH INSURANCE COMPANY |
Mutual of Omaha Insurance Company | Customer Service | 8558646797 | 83898 * | 23-OCT-2024 | Drug Benefit | Formulary--Protected Class Drugs | Missing protected class drug(s) during monthly formulary file submission window | Warning Letter.pdf |
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H6851 - BOSTON MEDICAL CENTER HEALTH PLAN, INC. |
BMC Health System, Inc. | Sherri-Ann de Medeiros | 8885660008 | 83277 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
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H9585 - BOSTON MEDICAL CENTER HEALTH PLAN, INC. |
BMC Health System, Inc. | Sherri-Ann de Medeiros | 8885660008 | 83278 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H4931 - BANNER - UNIVERSITY CARE ADVANTAGE |
Banner Health | Customer Care | 5208743930 | 83270 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5843 - BANNER HEALTH PLAN, INC. |
Banner Health | Customer Care | 5208743930 | 83271 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7273 - BANNER HEALTH INSURANCE GROUP |
Banner Health | Customer Care | 5208743930 | 83272 * | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H6396 - CARESOURCE OHIO, INC. |
CareSource | Chris Gengo | 9376600192 | 83280 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H8452 - CARESOURCE OHIO, INC. |
CareSource | Chris Gengo | 9375312288 | 83281 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5826 - COMMUNITY HEALTH PLAN OF WASHINGTON |
Community Health Plan of Washington | Customer Care | 8009420247 | 83300 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2320 - PRIORITY HEALTH |
Corewell Health | Customer Service | 8883896648 | 83324 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H4875 - PRIORITY HEALTH |
Corewell Health | Customer Service | 8883896648 | 83325 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3528 - CONNECTICARE, INC. |
EmblemHealth, Inc. | Member Services | 8006650898 | 83301 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3330 - HEALTH INSURANCE PLAN OF GREATER NEW YORK |
EmblemHealth, Inc. | Nicole Tirado | 8773447364 | 83303 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S5966 - EMBLEMHEALTH PLAN, INC |
EmblemHealth, Inc. | Nicole Tirado | 8773447364 | 83304 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7598 - GROUP HEALTH COOPERATIVE OF EAU CLAIRE |
Group Health Cooperative of Eau Claire | Adam Yang | 7158522984 | 83308 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H1099 - HEALTH FIRST HEALTH PLANS |
Health First Shared Services, Inc. | Katie Fleming | 8445225282 | 83310 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H9712 - HAP CareSource |
Henry Ford Health System | San Le | 6784249275 | 83282 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2322 - ALLIANCE HEALTH AND LIFE INSURANCE COMPANY |
Henry Ford Health System | Heather Spencer | 2487763808 | 83309 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3384 - Highmark Western and Northeastern New York Inc. |
Highmark Health | Customer Service | 8773271395 | 83311 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3916 - HIGHMARK SENIOR HEALTH COMPANY |
Highmark Health | Provider Service | 8665886967 | 83312 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
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H3957 - HIGHMARK CHOICE COMPANY |
Highmark Health | Provider Service | 8665886967 | 83313 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5106 - HIGHMARK SENIOR SOLUTIONS COMPANY |
Highmark Health | Provider Service | 8665886967 | 83314 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5526 - Highmark Western and Northeastern New York Inc. |
Highmark Health | Customer Service | 8773271395 | 83315 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
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H8166 - HIGHMARK BCBSD INC. |
Highmark Health | Provider Service | 8665886967 | 83316 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S1140 - Highmark Western and Northeastern New York Inc. |
Highmark Health | Customer Service | 8773271395 | 83317 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S5593 - HM HEALTH INSURANCE COMPANY |
Highmark Health | Provider Service | 8665886967 | 83318 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3335 - EXCELLUS HEALTH PLAN, INC. |
Lifetime Healthcare, Inc. | Ashley Wells | 5852383641 | 83305 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3351 - EXCELLUS HEALTH PLAN, INC. |
Lifetime Healthcare, Inc. | Ashley Wells | 5852383641 | 83306 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S3521 - EXCELLUS HEALTH PLAN, INC. |
Lifetime Healthcare, Inc. | Ashley Wells | 5852383641 | 83307 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H1248 - LOUISIANA HEALTH SERVICE & INDEMNITY COMPANY |
Louisiana Health Service & Indemnity Company | Customer Service | 8665087145 | 83273 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2722 - Primewell Health Services of Arkansas, Inc. |
Louisiana Health Service & Indemnity Company | Customer Service | 8665087145 | 83274 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H6453 - HMO LOUISIANA, INC. |
Louisiana Health Service & Indemnity Company | Customer Service | 8665087145 | 83275 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7163 - Primewell Health Services of Mississippi Inc. |
Louisiana Health Service & Indemnity Company | Customer Service | 8665087145 | 83276 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2450 - MEDICA INSURANCE COMPANY |
Medica Holding Company | Customer Service | 8002348755 | 83319 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H8889 - MEDICA HEALTH PLANS |
Medica Holding Company | Customer Service | 8002348755 | 83320 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H9952 - MEDICA HEALTH PLANS |
Medica Holding Company | Customer Service | 8002348755 | 83321 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H0838 - UNIVERSAL CARE, INC. |
Molina Healthcare, Inc. | Member Services | 8006650898 | 83279 * | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S7126 - OMAHA HEALTH INSURANCE COMPANY |
Mutual of Omaha Insurance Company | Customer Service | 8558646797 | 83322 * | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5215 - NETWORK HEALTH INSURANCE CORPORATION |
Network Health, Inc. | Customer Service | 8003785234 | 83323 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5425 - SCAN HEALTH PLAN |
SCAN Group | Kim McBeath | 8777787226 | 83326 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H1016 - AVMED, INC. |
Sentara Health Care (SHC) | Catherine Lojko | 3523728400 | 83327 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2563 - SENTARA HEALTH PLANS |
Sentara Health Care (SHC) | OPTIMA MEMBER SERVICES | 8009276048 | 83328 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S2465 - SENTARA HEALTH PLANS |
Sentara Health Care (SHC) | OPTIMA MEMBER SERVICES | 8009276048 | 83329 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H0354 - BRAVO HEALTH PENNSYLVANIA, INC. |
The Cigna Group | Mike Soltis | 6238063361 | 83283 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H0439 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83284 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H0672 - CIGNA HEALTHCARE OF COLORADO, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83285 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2108 - BRAVO HEALTH MID-ATLANTIC, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83286 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H2752 - BRAVO HEALTH PENNSYLVANIA, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83287 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3949 - BRAVO HEALTH PENNSYLVANIA, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83288 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H4407 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83289 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H4513 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83290 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H5410 - HEALTHSPRING OF FLORIDA, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83291 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7020 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83292 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7389 - HealthSpring Life & Health Insurance Company, Inc. |
The Cigna Group | Jared Rich | 6156364554 | 83293 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7787 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83294 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H7849 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83295 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H9460 - HEALTHSPRING LIFE & HEALTH INSURANCE COMPANY, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83296 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H9725 - BRAVO HEALTH PENNSYLVANIA, INC. |
The Cigna Group | Jared Rich | 6156364554 | 83297 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S5617 - MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY |
The Cigna Group | Jared Rich | 6156364554 | 83298 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
S5660 - MEDCO CONTAINMENT LIFE AND MEDCO CONTAINMENT NY |
The Cigna Group | Express Scripts-Medicare | 8665294917 | 83299 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3672 - THE HEALTH PLAN OF WEST VIRGINIA, INC. |
The Health Plan of West Virginia, Inc. | Penny Staffileno | 7406957597 | 83330 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H8604 - THP INSURANCE COMPANY |
The Health Plan of West Virginia, Inc. | Penny Staffileno | 7406957597 | 83331 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H3907 - UPMC HEALTH PLAN, INC. |
UPMC Health System | Medicare Marketing | 8773813765 | 83332 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
|
H4279 - UPMC FOR YOU, INC |
UPMC Health System | Medicare Marketing | 8773813765 | 83333 | 04-SEP-2024 | Drug Benefit | Payment to Providers | Failure to Incorporate Pharmacy Price Concessions at Point of Sale | Warning Letter.pdf |
| Report Created: 6/1/2025 | Report Sorted: Descending by Date Letter Sent | ||||||||
| Compliance Issue IDs followed by an asterisk (*) indicate that all contracts assigned to the issue have been terminated as of the report creation date | |||||||||