STATE OF NORTH CAROLINA



|STATE OF NORTH CAROLINA |IN THE OFFICE OF |

| |ADMINISTRATIVE HEARINGS |

|COUNTY OF MECKLENBURG |11 INS 2711 |

|Janet McKillop, |) |

|Petitioner, |) |

|v. |) DECISION |

|North Carolina Blue Cross Blue Shield of North Carolina State Health |) |

|Plan, |) |

|Respondent. |) |

On July 15, 2011, the undersigned conducted an administrative hearing in this case in Charlotte, NC. At the conclusion of the hearing, the undersigned ruled in favor of the Respondent and directed Respondent to submit a proposed decision. Having received a hardcopy of Respondent’s proposed decision, the record in the case is now closed.

APPEARANCES

For the Petitioner: Janet McKillop

3542 Manor House Dr.

Charlotte, NC 28270

For the Respondent: Heather H. Freeman

Assistant Attorney General

North Carolina Department of Justice

Post Office Box 629

Raleigh, NC 27602-0629

ISSUE

Did the Respondent substantially prejudice Petitioner’s rights, act erroneously, fail to use proper procedure or fail to act as required by law or rule when it denied the Petitioner’s claims for in-network coverage for out-of-network providers at the Hunter Hopkins Center?

RELEVANT STATUTES AND POLICIES

N.C. Gen. Stat. §135, N.C. Gen. Stat. Chapter 150B, Article 3; the State Health Plan PPO Benefit Booklet; and, BCBCNC PPO Access to Care Standard Driving Distance to providers guidelines.

EXHIBITS

For Petitioner: Exhibits 1, 2

For Respondent: Exhibits 1-10

WITNESSES

For Petitioner: Janet McKillop, on her own behalf.

For Respondent: Donna Williams, Appeals Team Lead, Blue Cross Blue Shield of North Carolina.

FINDINGS OF FACT

Based on a review of the witness testimony, exhibits and the record as a whole, it is found as a fact that:

1. Respondent is an agency of the State of North Carolina, and offers health care benefits to eligible active and retired employees and their enrolled dependants in accordance with the applicable North Carolina General Statutes, the benefit booklet for Respondent’s preferred provider organization (hereinafter “PPO”) plan, and Respondent’s health care policies.

2. At all times relevant to the issues in this contested case, Petitioner was a member of Respondent’s Standard PPO plan.

3. Blue Cross Blue Shield of North Carolina (BCBSNC) is the claims processing contractor for the State’s PPO plan.

4. In 2010, Petitioner received treatment for chronic fatigue syndrome from Dr. Laura Black at the Hunter Hopkins Center.

5. Claims were submitted to Respondent by the Hunter Hopkins Center, on behalf of Petitioner, for services from May 14, 2010 through August 12, 2010. Respondent processed Petitioner’s claims at the out-of-network benefit level.

6. Petitioner timely appealed the processing and payment of claims at the out-of-network level. R Ex 1

7. Petitioner’s appeal was denied and notice was provided by letter dated August 23, 2010. The letter states the basis of the denial and quotes the State Health Plan benefits booklet. R Ex 2

8. Under the section titled “HOW THE PPO PLAN WORKS” on page 4 of Respondent’s benefit booklet is a subsection titled “Out-Of-Network Benefits” which describes coverage of out-of-network benefits pursuant to the Standard PPO Plan, to wit:

With the PPO Plan, you may choose to receive covered services from an out-of-network provider and benefits will be paid at the lower out-of-network level. However, if the condition is an emergency, or if in-network providers are not reasonably available to the member as determined by BCBSNC’s access to care standards, benefits will be paid at the in-network benefit level.

R Ex 2 & 8

9. The August 23, 2010 denial letter from the State Health Plan states that there were numerous in-network providers available to treat Petitioner’s condition in Mecklenburg County. The letter further states that Respondent contacted three providers and confirmed that all three treated Petitioner’s condition. R Ex 2

10. Petitioner timely appealed the denial of her Level I appeal. R Ex 4

11. On January 13, 2011, a Level II Grievance Review Panel Meeting was held for final determination of Petitioner’s request for in-network benefits for Dr. Black’s services. Petitioner appeared at the January 13, 2011 panel meeting telephonically and presented her case to the panel. R Ex 5 & 6

12. Petitioner’s Level II appeal was denied and notice was provided by letter dated January 13, 2011. The letter states the basis of the denial. R Ex 7

13. Donna Williams, Appeals Team Lead for BCBSNC, testified on behalf of Respondent. Mrs. Williams stated that Dr. Charles Lapp and Dr. Laura Black were out-of-network providers located at the Hunter Hopkins Center, an out-of-network facility. Mrs. Williams testified that Petitioner received treatment from Dr. Laura Black at the Hunter Hopkins Center in 2010.

14. Mrs. Williams testified about BCBSNC’s Access to Care Standards. She further testified that Petitioner’s appeals for in-network benefits were denied because there were multiple in-network providers reasonably available to treat Petitioner’s condition within the BCBSNC Access to Care Standards. Mrs. Williams verified that Respondent contacted three different providers and confirmed that all three providers treated Petitioner’s condition. R Ex 3

15. Mrs. Williams explained that the panel members participating in the Level II Grievance Review Panel Meeting reviewed all previous appeal information, including all documentation provided by the member and documentation generated during the appeals. Based on her review of the file, Mrs. Williams testified that Petitioner had an opportunity to present her position to the panel members during the meeting.

16. Petitioner testified on her own behalf. Petitioner testified that she read her benefit booklet before she received treatment from Dr. Laura Black. Petitioner testified that she was aware that Dr. Black was an out-of-network provider prior to receiving treatment or services from Dr. Black at the Hunter Hopkins Center.

CONCLUSIONS OF LAW

1. The Office of Administrative Hearings has jurisdiction over this contested case and the parties thereto.

2. In N.C. Gen. Stat. Chapter 135, the General Assembly created a State Health Plan for the benefit of its state employees, retired employees and certain of their eligible dependants. Pursuant to N.C. Gen. Stat. Chapter 135, Respondent is to provide comprehensive medical coverage under a group plan and benefits are to be provided under contracts between the Plan and the claims processor.

3. Blue Cross Blue Shield of North Carolina (BCBSNC) is the claims processor for the State’s PPO Plan which Petitioner was a member.

4. Petitioner has the burden of proof in this matter by a preponderance of the evidence regarding the issues presented in this contested case. N.C. Gen. Stat. § 150B-34(a).

5. Respondent’s State Health Plan Benefit Booklet for the Standard PPO Plan sets forth the benefits available to members.

6. Petitioner did not meet her burden of proving that Respondent substantially prejudiced Petitioner’s rights, acted erroneously, failed to use proper procedure or failed to act as required by law or rule by denying Petitioner’s claim for in-network benefits.

DECISION

Based on the foregoing Findings of Fact and Conclusions of Law, the undersigned determines that the final decision maker should AFFIRM Respondent’s denial of Petitioner’s request for in-network benefits.

NOTICE AND ORDER

The agency that will make the final decision in this contested case is the Board of Trustees of the North Carolina State Health Plan (hereinafter “Agency”). The Agency is required to give each party the opportunity to file exceptions to and written arguments concerning this Recommended Decision. The Agency is further required to serve a copy of the Final Agency Decision on all Parties or their attorneys of record and on the Office of Administrative Hearings.

In accordance with N.C. Gen. Stat. §150B-36 the Agency shall adopt each finding of fact contained in the Administrative Law Judge’s decision unless the finding is clearly contrary to the preponderance of the admissible evidence. For each finding of fact not adopted by the Agency, the Agency shall set forth separately and in detail the reasons for not adopting the finding of fact and the evidence in the record relied upon by the Agency in not adopting the finding of fact. For each new finding of fact made by the agency that is not contained in the Administrative law Judge’s decision, the Agency shall set forth separately and in detail the evidence in the record relied upon by the agency in making the finding of fact. The party aggrieved by the Agency’s decision shall be entitled to immediate judicial review of the decision under Article 4 of this Chapter.

This 4th day of August, 2011.

______________________________

The Honorable Selina M. Brooks

Administrative Law Judge

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