Clark Insurance

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on March 1, Upon receipt of [redacted] ’s complaint, we reviewed her policy and found that the procedure in question is specifically excluded from coverage It was noted that first and second level appeals have been performed asking for coverage for the procedure but the decision to not allow coverage was upheld in both cases The phone calls [redacted] had made to Coventry were reviewed during the appeals processes and there were no instances of misquoted benefits found 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

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 see how we could obtain the member’s receipt and process the reimbursementWe were able to locate the reimbursement request and were able to have it processed for the reimbursementThe check was mailed to the member’s home address yesterday, February 17, We apologize for providing the incorrect form in the original responseIf the member has any further questions or concerns there will be contact information provided with the check reimbursement or he can contact the email address listed below 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 November 30, It was found that [redacted] was not considered as an authorized representative to act on his son’s behalf We were able to reach out to his son, [redacted] , to obtain the necessary authorization for this situation and have mailed him a form that can be completed to authorize his father to act on his behalf in the future Upon receiving the authorization from [redacted] , we provided the details of the resolution reached directly to [redacted] and he accepted our resolution Due to the protected health information involved, the details are not being given in this response We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MrKhattak’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 Ms [redacted] , Please see our response to complaint # [redacted] for [redacted] Jrthat was received by us on June 29, During our investigation of the complaint, it was confirmed that Mr [redacted] was given correct information on his previous contacts We will regrettably not be able to remove the $NSF fees that have been applied The Electronic Funds Transfer process does not provide the capability of determining if a bank account is open or closed at any given time That information is only sent to Coventry when a transaction is attempted Because of this, we are unable to prevent drafts from being scheduled to be taken out of an account that has been closed It is very important to ensure that valid account information is given every time a payment is scheduled All bank account information that we have been provided is stored with our member’s cases in our Billing and Enrollment system The account information can be removed from a case by sending in a Change Payment Method form or by using our website If an account is closed, new account information can be entered and the old account information can be removed so it is no longer possible to accidentally schedule a payment from the wrong one We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris B [redacted] Executive Resolution Team

Dear [redacted] : Please see our response to complaint # [redacted] for [redacted] that was received by us on February 23, 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 reached out to our Medicare department for investigation We were advised that the Rewards card program [redacted] mentioned is an incentive program that is part of Florida Medicare’s ongoing effort to encourage their members to obtain their preventive healthcare services Any point earned through the program must be redeemed by December 31stAll unused points will expire on December 31st of each yearWe regret that our decision is not more favorable to [redacted] The Rewards cards were sent out in late March and any returned cards would have been documented A returned card was not identified for him In 2018, [redacted] does have access to our OTC Benefit program This benefit allows a member to obtain over-the-counter items and non-prescription drugs that they would typically purchase for themselves that are not covered by Medicare The monthly allowance for the OTC Benefit is $per month Orders are limited to one per month and any unused benefit amount does not carry over Items may be ordered online at order.otchs.com or by calling a Member Services representative who can place the order for the person The telephone number for Member Services for [redacted] ’s plan is ###-###-#### Member Services can also order a catalog of the items offeredWe 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 BComplaints and Appeals Consultant Executive Resolution Team

October 1, 2015Although I am definitely NOT happy with the resolution, because who knows if or when this "computer glitch" issue could happen again, I have decided that it is pointless to keep going around & around Thank you very much for looking into this issue for me!Sincerely, [redacted]

[redacted] Please see our response to complaint [redacted] that was received by us on May 23, 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 found and reviewed the documentation previously submitted through Coventry’s online portal, My Online Services The documentation was then forwarded to our Claims department Work is ongoing to have the charges processed at this time Due to the complexity and length of the documents submitted, additional time is needed to finish the processing We expect the processing to be completed within – business days We apologize for and regret the delay Once processing is completed, a statement will be sent out with an explanation of our handling of the charges and a check for any eligible reimbursement 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 [redacted] *Regards, Chris B [redacted] ***

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on February 2, In reviewing [redacted] ’s policy, it was noted that she is covered on a self-insured plan through the [redacted] (***) We found that an authorization had been requested for a procedure used to treat lipodystrophy The request was reviewed by our Medical Director, Heather U [redacted] MD, and the request was denied The Plan Brochure for [redacted] ’s plan outlines the process for requesting reconsiderations of decisions that the person does not agree with The relevant section begins on page and continues through page The brochure states that the first level of appeal is initiated with [redacted] by writing to them at ***, P.OBox ***, Independence, MO [redacted] and including supporting documentation It goes on to say that if the person does not agree with the [redacted] decision, the next step in the review process can be started by writing to the Office Of Personnel Management (OPM) at United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 2, E Street NW, Washington, DC 20415- Filing to OPM is the last level of administrative appeals, so beyond that the next level of recourse is to file a lawsuit Please refer to the attached Plan Brochure for the full instruction on filing appeals and reconsiderations Lastly, we were able to locate the privacy policy for *** As they are a self-insured employer group, with Coventry Health Care acting as a business associate, [redacted] maintains the privacy policy and is responsible for providing the health information that [redacted] is requesting The form that can be used to request that information is attached, as is the privacy policy The form must be completed in full and can then be sent to ***, ATTN: Access Request, P.OBox ***, Independence, MO [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, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team / [redacted] Style Definitions */

[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 am rejecting this response because: AGAIN, I was mis-lead by a Coventry Representor over the phoneI’m not exactly sure what was heard over the recorded phone conference, but it appears to me that their saying that I wasn’t Mis-LeadBut I was!!!! What I do Know is that a Coventry representor told me that I would be covered for a breast reduction at 100% as long as I had documentations, showing that it was medically needed (ALL OF THAT INFORMATION WAS PROVIDED) And I stand behind my word at 100%Again, I called a plastic surgeon by the name of Dr [redacted] only to find out that they didn’t cover Coventry Insurance So that called lead me to called my Insurance Repto see if they could further assist me Coventry, were very precise with their information on what doctors would cover this procedures They even informed me that they could either email or faxed me a list of providers that were in-network In which they did Once I got the list I found a surgeon and proceeded with the process It really hurts badly, to know that my insurance provider will not cover this medically needed procedure I was informed that it had to be a reconstruction issues, then later I was told that was not not a cover procedures at all It looks to me that Coventry can do and say whatever they want to their customers, and pretend that they are doing all they can do to satisfied us!!! (NOT) it’s a shame that I can’t get any assistance from my paid insurance provider I have appeal this twice, with not success and file a formal complaint to the Revdex.com Hopeful my information will help another customer My advice would be to have it in writing Because you will need to have a strong leg to stand on, other than that we are out-numbered Regards, [redacted]

Dear Mr [redacted] : Please see our response to complaint # [redacted] for [redacted] that was received by us on December 31, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youIn reviewing Mr [redacted] ’s complaint, it was noted that he indicated the product/service he pur***d was [redacted] [redacted] is not directly affiliated with ***, Coventry Health Care, or [redacted] Our relationship with [redacted] is only through a network rental agreement that they have with [redacted] The agreement allows their membership to visit providers who are contracted with [redacted] and receive discounted rates for services As we do not have any involvement with the administration of the policy, we are unable to assist further with Mr [redacted] ’s request to terminate the policy or receive refunds of the premiums he has paid Our investigation indicated that [redacted] is part of [redacted] They would need to be contacted for further review of this issue We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [redacted] ’s 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 July 6, During our review we were not able to locate a call from [redacted] where he requested to cancel his policy Termination requests can be made over the phone by calling our Billing and Enrollment department at [redacted] I have also attached a termination form that can be filled out and faxed or mailed back to us The form lists the fax number and address for where to send it once completedThe plan will also terminate if premiums are not paid but we will not send a member to collections for unpaid premiums We found that [redacted] had previously filed complaint [redacted] with the Revdex.com and was provided with a copy of the letter we sent in that advised of the plan change for That letter contains a web address for the plan documentation We have attached a copy of the plan documentation and the renewal notice to this response as well He may also contact the Customer Service department at ###-###-#### if he has questions about benefits for specific services A one-time exception was made during the previous complaint review to reprocess the claims that we had received for [redacted] up to that point and apply the benefits for his plan from That process has been completed and he has been made aware of the new processing of the claims An exception will not be made to refund the premiums that have been paid for his policy 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 March 20, 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 reviewed the complaint again with our Billing and Enrollment departmentThe payments we received from the member totaled $She was issued a refund of $on or around July 2, The resulting net total of payments received is $The total owed for this time frame then is $As the amount paid is equal to the amount owed, no further refund is due Again we did note that the member stated her form only showed two months of coverage while Coventry’s systems show her having four months of active coverageHer policy was applied for through the Federal Health Insurance Marketplace (FHIM)The 1095-A form is sent by the FHIM and shows the months of active coverage that the FHIM has on fileWe reported the coverage dates for the member of January 1, 2016, to April 30, 2016, to the FHIMIf there is a discrepancy with the information shown on the form, corrections would need to be made by FHIM; Coventry is unable to update this information for the memberA review of the form can be requested by calling the Marketplace Call Center at ###-###-####Please have the member call the Marketplace to have this information updated for her tax recordsIf the Marketplace updates any information on the member’s plan this will be sent to Coventry for updating; this includes both the tax form and the refund request 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 February 19, Upon receipt of the complaint, we reviewed [redacted] ’s policy and found that a request had been made to update her address on December 9, The new address she gave was outside of the coverage area for the plan she had been enrolled on Unfortunately, it was not immediately noticed that the plan she was enrolled on was not offered where she now lives The issue was eventually detected, which is what generated the letter advising that policy was going to end as of March 31, We normally would only allow the coverage to continue for days from the end of the month when the address was changed Since it was not caught immediately, we instead allowed the coverage to remain active for days past the end of the month in which we sent the letter We also found that the payments were not collected in January and February due to issues with the address update not being processed properly That issue has been corrected and bills will now be generated for the amount owed The plan is still active at present and there does not appear to have been any disruption in the processing of [redacted] ’s claims for While we are not able to extend [redacted] ’s coverage under her current plan past March 31, 2016, we do offer other plans in the area where she now lives If she wishes to select one of the other plans, a new application would need to be sent The plan change would take effect April 1, 2016, which means that she would not have any lapse in coverage We have made several attempts to speak with her to discuss her options in continuing coverage with Coventry but have been unsuccessful in reaching her 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 January 8, In reviewing the concerns [redacted] reported, it was noted that she was required to provide her bank account information again for her coverage due to a new billing case being created The new billing case was created based on the way the Federal Health Insurance Marketplace sent the enrollment files to us We regret any frustration this caused The payment for the January premium was posted to her account on January 6, The last manual ID card request we found was from December 14, At that time, [redacted] had reported that she lost her ID card As the policy for was not yet active, the card mailed was for her coverage After receiving the payment for her coverage, a copy of her card was automatically mailed to the address we have on file Finally, we do apologize for any lengthy hold times that [redacted] has experienced recently Unfortunately, due to the increase in call volume during the open enrollment period, it can take longer to reach a representative at times The forty-five minute wait that she reported is not typical and we do strive to answer all calls as quickly as possible 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 July 16, It was determined that the delay in the enrollment for [redacted] ’s daughter’s policy was due to a document that had been requested that was needed in order to confirm her eligibility Upon receipt, the document was reviewed by our Underwriting department and the policy was created We noted that two payments were collected from [redacted] One was authorized through the application process and the other was scheduled on to a phone call to our Billing and Enrollment department The agent who she spoke with should not have scheduled the second payment and has been educated on the proper processes A refund check has been mailed to [redacted] for $ She will be responsible for the August premium once it becomes due if she wishes to continue the coverage A recording of the phone call with the supervisor that [redacted] spoke to could not be located so regrettably we are not able to determine the content of the call However, the person that she spoke with will be provided with coaching to ensure that high quality service is always provided Finally, we were able to speak with the doctor’s office that treated [redacted] ’s daughter We gave them the policy information and the instructions for claim submission The claim was received and processed on July 17, A payment was made to the provider on July 21, At this time, the claim is showing that the only member responsibility is a $copayment Any additional amount [redacted] paid to the doctor’s office will need to be refunded to her or issued as a credit on her account with them 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

-------- Forwarded message ----------From: Revdex.com of Metro Washington DCDate: Mon, Feb 22, at 8:AMSubject: Fwd:To: [redacted] @myRevdex.com.org---------- Forwarded message ----------From: [redacted] < [redacted] @***.com>Date: Sat, Feb 20, at 9:AMSubject: To: [email protected] is just a heartfelt and sincere vote of thanks for your help in solving my complaint, [redacted] [redacted]

Dear [redacted] : Please see our response to complaint # [redacted] for [redacted] that was received by us on January 26, 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 reached out to our Medicare Grievance and Appeals unit We were advised that the issue was reviewed and it was found that [redacted] had contacted the area that handles the Healthy Rewards program in August and was advised that in order to review the incentive he would have to report the visit to them by the December 31, It was also determined that the letters sent out regarding the program, subsequent to the initial post card, stated that he must report the required information within the eligibility period The eligible dates for the program in that letter are given as January 1, 2017, to December 31, Since the notice was not provided until after January 1, 2018, the program had expired and [redacted] would not qualify for the reward We regret any frustration or inconvenience this issue has caused him 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] @***.comRegards, 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 January 21, Upon receiving the complaint, we found that [redacted] is on a Medicare Part D plan We reached out to our Medicare Grievance team and found that they were already aware of the situation Contracted pharmacies cannot refuse to fill a medication because they feel they are underpaid This issue has been escalated to our Network Team to find a solution so that this does not happen in the future Until a solution can be found, should [redacted] be refused a medication, we advise that he ask the pharmacy to contact our Customer Service department at the number located on his ID card [redacted] had indicated that he paid the pharmacy out of his pocket for the medication We encourage him to submit a claim for reimbursement of the amount he paid A prescription claim form is attached that can be used to file for reimbursement Please note that a receipt from the pharmacy is required to be sent with the claim formThe receipt must include specific information including the patients name, the prescription number, the medicine’s national drug code number, the date of the fill, the metric quantity, the total charge, the number of day’s supply for the prescription, the pharmacy’s name, address, and [redacted] Number, and the prescribing physician’s National Provider Identification number In reviewing the messages [redacted] had sent through our online member portal, it was noted that attempts had been made to contact [redacted] by phone but were not successful A Grievance response letter was sent on January 15, 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 April 5, In reviewing [redacted] ’s complaint, it was noted that Trinessa is considered a maintenance medication We do allow two fills of maintenance medications at retail pharmacies, but in order to have additional fills covered on the plan, we require notification of the preference to remain with the retail pharmacy This requirement is outlined in the attached Individual Member Contract That document states: Certain Prescription Drugs which are prescribed for the treatment of long-term or chronic conditions are considered to be Maintenance Drugs under the terms of this ContractIf you are prescribed a Maintenance Drug, You may obtain the first prescription fill for a day supply and one additional refill at a Participating Pharmacy that is a retail pharmacyBefore receiving the third fill of the Maintenance Drug at the Participating Pharmacy that is a retail pharmacy, You must notify us of whether you want to use Your Mail Order Pharmacy benefit or continue to obtain your Maintenance Drug at Participating Pharmacy that is a retail pharmacyIf You fail to inform us of Your choice, then the third prescription fill (and any subsequent refill of the Maintenance Drug) at a retail pharmacy will not be CoveredYou may contact Us at any time to let Us know that You intent to use a Participating Pharmacy that is a retail pharmacy for future fills of Your Maintenance Drugs It was also noted that [redacted] does not intend to continue coverage with Coventry due to now being covered by a plan through her employer effective April 1, Her plan is through the Federal Health Insurance Marketplace so all termination requests must be made with the Marketplace At this time, we have not received a communication from the Marketplace advising us to terminate her policy If we do not receive a termination date from the Marketplace, the policy will remain active until the end of June in accordance with the day grace period guideline established by the Marketplace for members receiving an Advanced Premium Tax Credit At the end of the grace period, the policy will be terminated retroactively to the end of the month in which the grace period began In this case, if no other premium payments are received, the termination date would then be April 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] Complaints and Appeals Consultant

I have called in asking to cancel my insurance and was told I could not. My health insurance company is lying or did not update their records when I called. The fact of the matter remains that I have spent over 18 hours calling and fixing my health insurance. I have been lied to and forced to do a lot as a customer and have not been able to use my service for months due to misinformation. I need reimbursed for both my time and my health insurance premium as I have been being lied to and do not have any more time to fix what they have broken resulting in bills adding up that I should not have to pay because I have done my due diligence and beyond. Again I no longer have the time to do their job for them. I need to start seeing a discounted monthly premium (at least half) or reimbursed for the months I have asked to cancel my insurance and me being told I could not until "enrollment periods" as I was told. Complaint: [redacted] I am rejecting this response because: Regards, [redacted]