Clark Insurance

Dear [redacted] : Please see our response to complaint # [redacted] for [redacted] that was received by us on October 21, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the complaint, we reviewed our claims system and confirmed the details as described by [redacted] The physician that performed the procedure is out-of-network for her plan that was active at the time of the service and the claim was thus handled as out-of-network As a claim that processed as out-of-network is considered an adverse benefit determination, the next option available for reconsideration of the claim is to file an appeal We forwarded the information in the complaint to our Coventry Appeals department and they will contact [redacted] directly to continue the process We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.comRegards, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed as Answered] Complaint: [redacted] I am rejecting this response because:I was covered by another insurance policy at the time Please see the attached letter I have essentially been billed by two separate insurance companies for the same month of coverage I have contacted the Healthcare Marketplace and have a case opened to reinvestigate what the situation is I had initial gone through the escalation process with the Marketplace back in and thought the issue had been resolved I question Coventry's ability to withdraw funds from a clients account from years ago with little explanationAs many consumers, I assume that you balance your accounts on an annual basis and don't leave the door open to withdraw funds at any time If you find a discrepancy contacting that individual and having a conversation might glean some insight into what has happened Sending out a form letter covers your butt for notification but does little to instill trust and dialogue with your clientsI also have found the way your customer service team and billing clerk handled the situation increased the level of misunderstanding and stress involved in figuring out just what was going onAgain, as stated in my previous complaint I received multiple stories as to what happened and still haven't received a callback from Gail after failed attempts Obviously this issue is one that I am following up with the Health Care Marketplace and hope to have resolved within the next days Perhaps through the Marketplace, [redacted] and Coventry can communicate with one another and figure out why both are claiming they can bill me for insurance If you have any power to provide customer service I would hope you will see there has been some misunderstanding and will actively communicate with parties involved to get this issue resolved Regards, [redacted] ***

[A default letter is provided here which indicates your acceptance of the business's response If you wish, you may update it before sending it.] Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me Regards, [redacted]

Dear Ms [redacted] ,Please see our response to complaint # [redacted] for [redacted] that was received by us on February 23, 2016.In reviewing the prescription claim history for the policy that covered Mrs [redacted] and her family, it was noted that there were several claims for her children that were not allowed for coverage as the medications that were being filled required prior authorization with Coventry in order to be covered Prior authorization had not been obtained for the medications It was confirmed that the plan documentation states that some medications may require authorization for coverage and the medications in question are listed on our prescription formulary as requiring that authorization The formulary and the plan documents are attached to this response As the plan guidelines are specifically outlined, the claim denials have been deemed appropriate and a refund of the premiums paid for the policy will not be issued We have reached out to Mrs [redacted] to discuss the situation but were unsuccessful in reaching her She may contact me directly at ###-###-#### to discuss the situation further and be provided copies of the prior authorization criteriaWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs [redacted] ’ concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] .Regards, Chris B [redacted] Complaints and Appeals ConsultantExecutive Resolution Team

Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to our Customer Service department to have the calls pulled that took place prior to the procedure being rendered to verify what information was provided to the memberThere were two calls on file that we had reviewed and the member was advised that the procedure would be covered at 100% with no copay if the procedure was billed as a routine/preventative service but if the service was billed as a medical/diagnostic reason then it applies towards the member’s deductible of $5,The representative on the last call verified where the procedure was being done and verified they were in network with her plan We also reached out to our Claims department to verify how the procedure was billed by the facilityWe verified the claim was submitted with medical diagnosis codes and not preventative codes which caused the claim to apply to the member’s deductibleAt this time the claim is processed correctly under the plan since it was billed with a medical/diagnostic reason and not as preventative We attempted to call the provider to verify if these services were billed correctly but they would not speak to us about the member’s diagnosisPlease contact your provider and discuss how they billed this claim and if it was billed incorrectly the provider may resubmit a corrected claim for reconsideration We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Thank you, Ashley S Complaint and Appeal Consultant Executive Resolution Team

Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on January 6, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the complaint, we noted that [redacted] *** did not provide her mother’s name, so we were unable to fully confirm the policy affected We attempted to speak with [redacted] *** over the phone at the number provided, but our calls were not answered or returned In order to pursue the issue, [redacted] should provide her mother’s name and the membership ID number for the policy In addition, the attached Appointment of Representative form will need to be completed and returned to us We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team

Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on August 10, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the request by the member we contacted the facility today August 17, 2016, after providing a week for their billing department to review the Explanation of Benefits (EOB)We were advised today by Destiny in the billing area that the member’s bill was adjusted yesterday August 16, 2016, to show the true owed amountThe adjusted bill also includes the money paid up front by the member and we confirmed he owes $A new bill is being generated this week to be sent to the member We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.comSincerely, Ashley W.Complaint and Appeals ConsultantExecutive Resolution Team

Dear [redacted] : Please see our response below to the additional concerns reported in complaint # [redacted] for [redacted] that were received by us on July 12, Upon receipt of [redacted] ***’s additional concerns, we reached out to our Billing and Enrollment department for further review Additional corrections were made to the policy when we made contact with them After their review, they stated that the billing case for one of [redacted] ***’s children had been updated and now showed that it was paid through July 31, 2016, while the other was showing paid through May 31, Once those updates were made, we contacted [redacted] who disagreed with the outcome of the review the Billing and Enrollment department had performed We requested that he submit a statement from his financial institution to support the amount that he was saying had been paid to Coventry The statement was provided July 21, 2016, and did show that the amount he had paid was different than the amount credited to the billing cases for his children We have submitted a request to have the necessary corrections made Those corrections will result in both policies being paid through July 31, 2016, with small credits applied towards the premiums owed for the month of August We expect for the updates to be completed by July 25, 2016, and will follow up with [redacted] when they are finishedWe apologize for and regret the frustration [redacted] has experienced during the resolution of this issue We have spoken with management in the appropriate areas in order to ensure that any opportunities for improvement are identified and the proper feedback provided to all representatives who have participatedWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ***’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.comSincerely, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team

Dear [redacted] , Please see our response below to the additional concerns reported in complaint # [redacted] for Terri Spiegel that were received by us on September 21, We did not mean to cause further aggravation or frustration for [redacted] in denying her requested refund The Department of Health and Human Services oversees the Marketplace policies and discourages premiums from being waived This is especially true in cases where Advanced Premium Tax Credits are being paid, due to the impact the premiums and tax credits have on determining a person’s income tax liability Coventry did speak with the provider’s office in question While we were not able to determine what [redacted] was advised by that office, we were able to confirm that they are still in network and that the office staff was aware We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Sincerely, Chris B [redacted] Complaints and Appeals Consultant - Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed as Answered] Complaint: [redacted] I am rejecting this response because: In regards to removing my daughter from my policy, I have spoke to many customer service representatives and told them directly to remove her, they all agreed and promised me they will do soNobody told me I have to send a letter as written proof to remove herThe most recent times I called to double check to make sure they removed her, they told me "Mom, don't worry your daughter has already been removed from the policy," only to find bills being sent to my house and doctors officeI called the market place too and they put me on hold millions of times because they told me they have removed herI have all the paper work that says my daughter is with her new insurance as of 2/1/2016, her being on Coventry's plan was supposed to end December of 2015, Coventry nor Market place never even sent me a notice when it was endingThis is my first time hearing that it was supposed to end December of Regards, [redacted]

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on March 11, In reviewing [redacted] ’s complaint, it was noted that Coventry had received enrollment files from the Federal Health Insurance Marketplace on or around September 16, 2015, that showed he and his spouse were no longer eligible for an Advanced Premium Tax Credit (APTC) effective October 1, This meant the total premium became his amount to pay for the coverage each month going forward The total premium for the plan was $525.20, and that was the amount collected each month [redacted] has stated that his wife was to be removed from the policy and his APTC reinstated in October We did receive files which showed his wife was no longer to be covered on the plan and that [redacted] is eligible for an APTC again effective January 1, 2016, but none have been received for the plan year We will continue to work with [redacted] and the Marketplace in attempting to get the supporting documentation that will allow us to make the changes he is requesting Until those updates are made, we are unable to issue a refund as the premiums collected match what the Marketplace has advised us is owed for each month of coverage We apologize for any frustration he has experienced during this situation We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Regards, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on February 22, During our review, it was determined that the letter [redacted] states she received on February 17, 2016, was generated from an incorrect file that was corrected in the previous caseThe letter seems to have gone out before the file was updated The member may disregard the letter, as nothing was deducted on February 29, as the member states the letter advised In addition, we verified with our Billing and Enrollment department that the member made a payment on February 26, The next premium payment will be due on March 31, for the April premium [redacted] has a monthly premium of $At this moment, the member is on paper billing, if the member would like to enroll into Electronic Funds Transfer (EFT) the member may call our Billing and Enrollment department at ###-###-#### to set it up I apologize for any difficulties this situation has caused [redacted] We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Regards, Julian C [redacted] Executive Resolution Team

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed Administratively Resolved] Complaint: [redacted] I am rejecting this response because: I called and left a message for my case manager last Friday and he has yet to return my phone call days laterThis is par for the course as his has happened for the last monthsEvery manager has said they would call me back and none do Regards, [redacted]

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on August 21, We regret any frustration that [redacted] experienced while attempting to locate providers We strive to keep our provider directories as up to date as possible It was determined that [redacted] had contacted the [redacted] of Palm Beach, as she had found them through our provider search She stated that they had told her that they were not participating with Coventry We contacted their office and they did confirm that they are still in the network for [redacted] ’s plan and were not able to offer a specific reason why she would have been told differently If she has additional providers that are stating they are out of network but show up on our directory, we ask that she call our Customer Service department at ###-###-#### so we may investigate further In regards to the second part of [redacted] ’s complaint, it was found that a system issue did cause her payment for the August premium to be scheduled for a penny less than the amount owed As the payment was already past the due date, this caused the policy to enter into a grace period While claims would have still been processed as during the first month of the grace period, a message is displayed on our website that providers use to review eligibility which led to them seeing the “hold” on the accountTechnicians are working to correct the problem so that the same issue does not happen in the future when using our automated phone system for payments [redacted] is on a policy applied for through the Federal Marketplace and is receiving an Advanced Premium Tax Credit Unfortunately, we are unable to waive the premiums for these policies While we do not wish to lose [redacted] ’s business, we can’t refund the past premiums she has paid or discount her future premiums The policy is currently paid through the end of September and the October premium is due on September 30, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Regards, Chris B [redacted] Executive Resolution Team

Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on October 31, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to the member to gather additional information to better assist in the requestWe stayed in touch with the member and were able to confirm that she no longer had an active policy with CoventryThis morning November 08, 2016, I email the member directly a letter that stated she no longer had active coverage with Coventry to provide to Medicaid and keep for her recordsShe has my direct contact information if anything further is needed to provide to Medicaid to update her files I apologize for the frustrations and difficulties she encountered while attempting to resolve this issue and regret that this matter required much of her time in order to facilitate a resolutionWe do appreciate her patience during the time involved in researching and resolving the issue We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Sincerely, Ashley WComplaint and Appeals Consultant Executive Resolution Team

Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on October 6, During our review, we found that [redacted] was covered on our SIL $CPPO METRO MO plan beginning on December 1, The policy was passively renewed and she was moved to the SIL $CPPO MO plan effective January 1, With the new plan, a higher premium applied and her Advanced Premium Tax Credit did not increase so the portion she was asked to pay went up Her amount to pay per month for the plan in was $ The amount increased to $with the plan for We were able to locate a renewal notice that was sent to her that stated the new amount for but it is dated January 12, 2015, in our system which was after the renewal had already taken place We regret the delay in providing the renewal notice [redacted] was set up for her premiums to draft automatically from her bank account, so an adjusted pull letter dated December 19, 2014, was sent advising her of the increased amount that would be drafted from her account even though the renewal notice had not generated A phone call to Coventry by [redacted] on December 15, 2014, was also located where she was advised of the plan change and new premium amount Upon further review, we also noted that adjustments were applied to her billing case which effectively reduced the amount she was asked to pay for the January and February premiums to the amount she was asked to pay prior to the renewal Our investigation into the adjustments is still ongoing but they may have been performed due to the late renewal notice being sent [redacted] prescription claims history was also reviewed There were several claims that were denied but not all of the denials were for the same reason One claim was denied due to it being submitted by a retail pharmacy for more than a day supply of a medication The denial was applied because her plan requires that fills for more than a day supply be done through our mail order pharmacy Another claim denied due to it being submitted for a quantity that was higher than what the plan allows The medication is only allowed at four pills per fill and the claim was submitted for six Finally, the most common denial was applied due to the length of time in between submission of an allowed claim and the submission of a claim for the next refillOur system monitors the number of days supply dispensed for each medication and will not allow another claim for the medication until the estimated days supply remaining drops below a certain threshold The system will monitor all previous claims when determining when to allow the next refill and does not only look at the previous claim which can lead to a varying length of time in between any two allowed claims The last part of [redacted] ’s complaint dealt with the issues she experienced and the service she received when trying to change her termination date from October 1, 2015, to September 30, We reviewed the files Coventry received from the Marketplace and they did provide the termination date of October 1, 2015, which leaves the policy still active for that day Coventry is not able to deviate from the termination date provided by the Marketplace so she would need to contact them in order to attempt to get the policy terminated a day earlier than what they had previously sent to us If she would like, a representative can be assigned to help her in contacting the Marketplace and requesting the change We have forwarded the information provided by her to the correct area to give any necessary feedback to the Billing and Enrollment representatives and supervisor she had spoken with We do apologize for any service provided that did not meet the high quality standards to which we hold ourselves Our review of [redacted] ’s payment history showed that a payment for $for the premium for October had been scheduled to be drafted from her bank account prior to the termination file being received The draft was not cancelled so that amount was collected After the payment was posted, a proration calculation was done for October that showed she owed $for each day of coverage in that month Since the policy was active for only one day, she was only responsible for $and the remaining $that had been collected was refunded directly into the bank account on record with an estimated posting date of October 8, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris Bi [redacted] Complaints and Appeals Consultant Executive Resolution Team

Dear [redacted] : Please see our response to complaint # [redacted] for [redacted] that was received by us on enter complaint received dateOur Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to our Billing and Enrollment department to have the member’s concerns reviewedWe were advised that they are currently reviewing the complete history of payment’s on file for the memberWe are still in the process of reviewing the history so that we may provide the member with the complete refund he is owedWe sincerely apologize this is taking longer than expected but we want to be sure the member gets the full refund owedWe will contact the member directly with the resolution We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ***’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @aetna.com Sincerely, Ashley WComplaint and Appeals Consultant Executive Resolution Team

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on June 15, During our review, it was determined that the member’s initial binder payment was made May 30, This posted to the policy on June 01, I confirmed with our Billing and Enrollment department that the member’s ID card was sent on June 02, When a binder payment is posted it can take about 7-business days for member’s to receive their ID cards in the mailAn update from the Marketplace was received on June 10, 2015, terminating the member’s coverage effective June 25, The member’s final bill and a refund for the remaining days of the month will be refunded within 7-business days I apologize for any difficulties this situation has caused [redacted] ***We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ***’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @aetna.com Regards, Julian C [redacted] Executive Resolution Team

Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] I am pleased that this matter is finally resolvedUnfortunately, it required three weeks of follow up calls to Coventry and a complaint to the Revdex.comI appreciate your assistance as I received a satisfactory resolution within day of filing the complaintThank you! Regards, [redacted]

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on October 16, In review of [redacted] ’s and her husband’s policies, it was noted that several enrollment issues had occurred surrounding the addition of her newborn twins to the correct plan During the initial attempt to correct the problem, claims were reprocessed and applied different amounts towards the deductible than they had initially When considering bills sent by providers at different times prior to and after the corrections, there was an overage that was applied However, [redacted] will only be responsible for the final amount applied towards the deductible for each claim The current total amount applied towards her and her sons’ deductibles does not exceed $for any individual person or $for the family We were able to contact [redacted] and explain our resolution of the situation and sent her a report that accurately shows which claims the deductible was applied on and which amounts she will owe to the different providers We have also made all necessary corrections to the enrollment for her family and gave the correct ID numbers for claim submission in the future We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @***.com Regards, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team