Resources Pleading and Exhibits The Knox Keene Act PEMCHA
FairHealth.org CalPERS’ & Anthem’s Breach of PEMCHA & Knox Keene Act
Breach of Contract Breach of Fiduciary Duties Unfair Business Practices
Administrative Process, Tolling, Delayed Accrual
Resources
Pleadings
Heinz v. CalPERS Anthem Does Complaint (Filed June 13, 2017)
Petition for Relief of Late Claim (Filed June 13, 2017)
Complaint(June 13, 2017)
Redacted Opening Brief on Petition for Writ of Administrative Mandamus ( November 27, 2018)
Exhibit List for Complaint
(Available for download)
| Exhibit Number | Title |
| 1 | CalPERS final administrative decision, with denial of reconsideration |
| 2 | VCA filing notice- no jurisdiction |
| 3 | CalPERS April 30, 2010 letter to Heinz |
| 4 | Heinz’s May 26, 2010 Letter to Heinz |
| 5 | Anthem Statement May 2008 , Claim Form, Walker Bill charging $420 for 45 to 50 min session and listing cognitive service at 90807 as CPT code, |
| 6 | Anthem Statement June 2008 |
| 7 | Anthem Statement for July August 2008 |
| 8 | Anthem claims processing December 2008 |
| 9 | Anthem statement September 2008 |
| 10 | Anthem statement November December 2008 |
| 11 | Anthem Statement January to April 2009 |
| 12 | Heinz Member Grievance Form September 2008 |
| 13 | Anthem reply re grievance rec 10-22-2008 |
| 14 | Appeal received 11/07/08 inquiry detail , on second page reads:’ this member has seen the same Dr. under a different PPO tx id # and the contracted rate was $$299.57 for 90807 |
| 15 | Anthem’s denial to Heinz grievance and response to appeal rec 11/7/08, and indicating to Heinz to change his doctor |
| 16 | Heinz first appeal on November 24, 2008 to Anthem after Anthem denial |
| 17 | Anthem’s revised denial of January 27, 2009 |
| 18 | Anthem receipt and recognition of second appeal, April 15, 2009 |
| 19 | Heinz renewed and continued appeal letter of June 15, 2009, including Anthem April 15, 2009 denial, and Anthem’s response to Heinz’s appeal on January 27, 2009 |
| 20 | Heinz demand letter to CalPERS, for nonaction, checking up on grievance December 27, 2009 |
| 21 | Heinz demand letter to CalPERS checking on Anthem grievance March 17, 2010, submitting documentation on under-reimbursement |
| 22 | Heinz demand letter to CalPERS requesting follow-up on grievance dated April 22, 2010 |
| 23 | Anthem inquiry tracking indicating that the allowable amount between 2008 -2010: $113,31. The allowable amount from 2010 to 7/28/11 was $128.41, From 11/08/11 to 11/22/13 :$76.91 and 05/03/13 – current (8/29/14): $136.86 |
| 24 | Evidence for Coverage (EOC) For 2008 |
| 25 | Evidence for Coverage (EOC) For 2009 |
| 26 | Evidence for Coverage (EOC) For 2010 |
| 27 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2008 |
| 28 | Evidence of Coverage(EOC) for 2014 |
| 29 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2009-2010 |
| 30 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2010 |
| 31 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2010-2011 |
| 32 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2011-12 |
| 33 | Heinz’s demand for information |
| 34 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2012-2013 |
| 35 | Public Records Request for info |
| 36 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2013 |
| 37 | CalPERS PRA response |
| 38 | Heinz’s medical claims, appeal, processing, presentation and reimbursement for 2014 |
| 39 | Heinz open enrollment form and standardized process $955 premium |
| 40 | Heinz open enrollment standardized form 2009 $1488 premium |
| 41 | Addendum to EOC (2012) |
| 42 | Addendum to EOC (2011) |
| 43 | Evidence for Coverage (EOC) For 2012 |
| 44 | Evidence for Coverage (EOC) For 2011 |
| 45 | Evidence for Coverage (EOC) For 2013 |
| 46 | Summary of Health Benefits Promo (2012) |
| 47 | Summary of Health Benefits Promo |
| 48 | Summary of Health Benefits (2014) |
| 49 | Summary of Health Benefits (2011) |
| 50 | Summary of Health Benefits (2010) |
| 51 | Summary of Health Benefits (2011) |
| 52 | Summary of Health Benefits (2008) |
| 53 | Summary of Benefits PERS choice 2009 |
| 54 | CalPERS PRA response- Administrative process ongoing to present |
| 55 | CalPERS circular letter re open enrollment PPO coverage |
| 56 | Litigation Hold letters for Electronically Stored Info (ESI) |
| 57 | Litigation Hold letters for Electronically Stored Info (ESI) |
| 58 | State of New York Attorney General Ingenix litigation information |
| 59 | Difference in premiums for PPO coverages |
| 60 | CalPERS Facts at a glance, page 7 indicates that 25.7 percent of CalPERS members enroll in PPO coverage or about 365,572 members. |
| 61 | Fair Health data on UCR rates show a $200 Estimates charge which is equivalent to Allowable Amount for 60 minutes of Psychotherapy service coded 90837 in SF and a Medicare reimbursement rate of $200 as well |
Evidence of Coverage
