Resources

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)

 

 

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