Clark Insurance

[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:Hello , Here is the bank statements , ***.They will show payments accepted on the *** but payments takenOne payment was refunded but the other was notSo the representive is wrong, they owe me a payment refunded.Thank you, [redacted] Regards, [redacted]

Dear *** ***,
Please see our response to complaint #*** for *** *** that was received by us on December 28,
During our review, it was determined that the member’s date of birth was submitted to Coventry from the Marketplace incorrectly, causing the claims for *** ***s to
denyIn order to correct this and have *** ***’s claims processed, a corrected date of birth would need to be received from the Marketplace via an update fileUnfortunately, this is not something Coventry can update manually as this is a Marketplace policy
An outbound call was placed to *** ***s on January 7, by our Billing and Enrollment department so that a conference call could be conducted with *** ***s, and the Marketplace, in order to have them submit a file to correct the date of birthThere was no answer from *** ***s so a detailed voicemail was left including the nature of the call and call back number ###-###-#### Ext ***
I apologize for any difficulties or confusion this may have caused *** ***We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com
Regards,
Julian C***
Executive Resolution Team

Dear *** ***: Please see our response to complaint #*** for *** *** that was received by us on October 31, 2016. 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 Billing and Enrollment systems to determine the exact amount of any refund owed to *** ***. Her monthly premium was $and that full amount was paid for August. Her policy was terminated shortly after the payment was collected with the last day of coverage being August 16, 2016. The prorated portion of the premium owed for the period of active coverage was calculated as $69.51. The difference between the amount paid and the amount actually owed is $65.17. We noted that our systems are showing *** *** was issued a refund of $on or around October 17, 2016. As her premium payments had been made through Electronic Funds Transfer (EFT), the refund was issued through EFT to the account that the premiums had been drafted from. We apologize for and regret any frustration or inconvenience she experienced while waiting for the refund to be issued. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.comRegards, Chris B*** Complaints and Appeals Consultant Executive Resolution Team

Dear *** ***: Please see our response to complaint #*** for *** *** that was received by us on August 4, 2016. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of *** ***’s complaint, we
reviewed the claim in question and found that the amount we had applied as his amount to pay was $which included $as a copayment and $as deductible. The plan had made a payment of $and there was a contractual reduction of $8180.03. We determined that the hospital was billing *** *** for the contractual reduction which was not an amount he was responsible for payingWe contacted *** *** and explained the benefits applied on the claim and where to find the documents that outline those benefits. He agreed that the Summary of Benefits and Coverage reflect that there is a copayment that applies only after the deductible for the plan has been met. We also received contact information for the hospital’s billing department from him. We were able to speak with a representative from the hospital’s billing department and provided them with documentation showing the amount of the contractual reduction. They stated they will review the documentation and contact Coventry with additional inquiries. This information was provided to *** *** along with my direct telephone number which can be used in the event that the hospital persists in billing him. It was also noted that an appeal has been received from *** *** regarding the processing of the claimThe appeal review is performed by a different department within Coventry Health Care. A response will be provided to *** *** by the Appeals department upon completion of their reviewWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.comRegards, Chris B*** Complaints and Appeals Consultant Executive Resolution Team

[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 ***, and find that this resolution is satisfactory to me.
Regards,
*** ***

Hello,
Thank you for your inquiry, regarding complaint #*** for *** ***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 Claims department to find out
why the member’s claim has not been paid out to the provider yetWe were advised that we are the secondary insurance and the member had other coverage at the time of service that was primaryThe explanation of benefits (EOB) that we received stated that the primary insurance denied because the claim benefits have already been considered and that the max benefit was reachedCoventry did process the denial correctly as we would need the primary insurance's original EOB that shows either a payment was made or has different denial reason then a duplicate claimIf the member is able to provide this documentation from the primary insurance we will be able to review to see if the claim is able to be reconsidered for additional payments
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Dear
*** ***,
Please
see our response to complaint #*** for *** *** that was received by us on January 4,
In
reviewing the prescription claim in question, it was found that *** ***’s
pharmacy had submitted the claim with a discontinued National Drug
Code (NDC). Without having a valid NDC we are unable to
allow the claim. The denial reason code
sent back to the pharmacy specifically states that was the reason for the denial
We
did also review *** ***’s prescription benefits and found that the
medication is a tier or non-preferred medication. When using an in network provider, tier
medications apply towards the $deductible until it is met. A
Summary of Benefits and Coverage is attached for his plan which supports
that statement, as is the prescription formulary which lists the medication
as tier
It
was noted that *** ***’s still has an active policy with Coventry for
as well. All terminations must be
submitted through the Federal Health Insurance Marketplace. If he wishes to cancel his policy he may
contact the Marketplace at ###-###-####
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address *** ***’s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at ***@***.com
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear *** ***,Please see our response to complaint #*** for *** *** that was received by us on April 1, 2016.Upon receipt of the complaint, we reached out to our Medicare Grievance and Appeals team for assistance. It was determined that an
authorization that had been requested to allow coverage of rehabilitation at *** *** *** was not approved. The reason for not approving the rehabilitation stay was that the medical necessity criteria, which are based on Medicare guidelines, were not met. Specifically, the requirements for coverage are that skilled nursing care and rehabilitation services are needed every day and are reasonable and necessary for the treatment of an illness or injury. It was found that the services *** ***’s father required could have been provided in an outpatient setting, at a long-term care facility, or through home care.An appeal has been submitted to review the denial of the authorization. We will make every effort to respond to the appeal as soon as possible, but will respond no later than days from the date we received the request. A separate resolution letter will be mailed to the address we have on file for *** ***’s father with the outcome of the appeal.It was stated that *** *** also wishes to be able to immediately switch insurance plans and be refunded the premiums that have been paid since January. We are unable to refund any of the premiums collected for a period of active coveragePlease note, Medicare will also generally only allow members to make plan changes at certain times of the year. These periods are known as the Annual Enrollment Period (AEP), which runs from October 15th through December 7th, and the Medicare Annual Disenrollment Period (MADP), which runs from January 1st through February 14th. Outside of AEP and MADP, a valid Special Enrollment Period (SEP) reason would be required in order to determine eligibility to change or end your membership. For more information about SEPs, *** *** may call Medicare at 1-800-Medicare (###-###-####).It was also requested that compensation be provided for home care services that were received upon *** ***’s father being denied access to Span Crest Manor. Our research shows that a home health care provider submitted a claim for at least some of the services that were provided. On the claim, the plan paid 100% of eligible expenses, and left no member responsibility. If there were any other charges that they have paid for out of pocket they may submit a request for member reimbursement under the home health care benefitSubmission of a reimbursement form is not required when requesting the reimbursementInstead, an itemized bill along with proof of payment, showing full payment, can be sent to the claims address at PO Box ***, London, KY ***-***The patient’s member ID number should also be included with the requestRequests for reimbursement can be submitted up to days from the date the service was provided.At this time, we would like to extend our apologies for any inconvenience that *** *** or her father may have encounteredAll feedback is shared with Health America’s leadership so we can make future improvements. If more information is needed in regards to the response provided, *** *** may contact the Medicare Grievance representative who reviewed the situation, Tomeca Haynes, at ###-###-####If there are any questions about the benefits of the plan, she may also contact our Member Services Department at ###-###-####.We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com.Regards,Chris B***Complaints and Appeals ConsultantExecutive Resolution Team

Dear *** ***:Please see our response to complaint #*** for *** *** that was received by us on January 30, 2017. 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 reached
out to *** *** to get additional information about the bank account that the premiums were being collected fromAfter reviewing the information she provided with our Billing and Enrollment department, it was found that a policy for a person other than *** *** had been set to automatically collect premiums from her bank account since January of 2014. A cancellation request was not received for that policy at the end of 2015, and it was renewed for 2016. Because of this, the premiums continued to be taken out of the account on file until a stop payment was placed with *** ***’s bank to prevent further Electronic Fund Transfers from the account. We reviewed the application for the other associated policy and noted that it does have *** ***’s bank account information and shows as having been electronically signed by her. We have contacted *** *** directly regarding this issue As the required renewal notices were sent by Coventry and the premium collection was authorized by *** ***, we are unable to retroactively terminate the policy or refund the payments to her. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com.Regards,Christopher B***Complaint and Appeals ConsultantExecutive Resolution Team

[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 ***, and find that this resolution is satisfactory to me.
Regards,
*** ***

Dear *** ***: Please see our response to complaint #*** for *** *** that was received by us on November 4, 2016. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of *** ***’s complaint, we
reached out to our Billing and Enrollment department, as they handle incoming applications. We verified the fax number that was given, ###-###-#### is correct. However, after an exhaustive search the application was still not found. In order to proceed with her request for coverage to become effective November 1, 2016, the application and proof of the prior submission of the application will be required. Those documents can be faxed directly to the Executive Resolution Team’s secure fax line at ###-###-#### or e-mailed to us at ***@***.comAs noted in the comments from *** ***, a case has been launched for review of her concerns and is being handled by a separate representative. Neil is a member of the Executive Resolution Team and will continue to offer his assistance to *** *** and will be contacting her directly. We apologize for and regret any frustration or inconvenience *** *** 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 *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com Regards, Chris B*** Complaints and Appeals Consultant Executive Resolution Team

Dear Ms***: Please see our response to complaint #*** from *** *** that was received by us on December 09, 2016. Our Executive Resolution Team (ERT) researched your concerns, and I would like to share the results of the review with youUpon receipt of the complaint, we
immediately reviewed our systems and noted that Mrand Mrs***’s policy was not considered as past due at that time. We discovered that the issue began with the premium payment for their policy for November not being received until November 30, 2016. The premium had been due October 31, 2016. In order to facilitate the grace period process for members of Federal Health Insurance Marketplace (FHIM) policies receiving Advanced Premium Tax Credits (APTC), we have a process in place that adds a note in our systems to begin to deny claims beginning the second month for which the premium is not brought current. While the note does not take effect until the first of the second month of the policy being past due, it is added in advance to allow time for all areas of the system to be updated with the note as it takes three to five days for all information to be sent to the different systems electronically. Once the policy is brought back current the electronic updates to remove the note also take three to five days, but the updates can be expedited in urgent life-threatening situations. Although the November premium payment was posted on November 30, 2016, and the December premium payment was posted on December 1, 2016, this did not allow enough time for the grace period note to be removed electronicallyThe documentation from Mr***’s call to our Billing and Enrollment department after he made the payments states that he advised the issue was not life threatening so the updates were not expeditedThe updates were completed according to the standard processing times on December 6, 2016. The prescription claims for Mrs*** were then refiled by the pharmacy on December 7, 2016, and processed according to their benefit plan. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *** Regards, Chris B*** Complaints and Appeals Consultant Executive Resolution Team Tell us why here

Dear *** ***, Please see our response to complaint #*** for *** *** that was received by us on May 16, Upon receipt of the complaint, we immediately reached out to our Billing and Enrollment department. It was found that improper adjustments being made to his
account and a refund that was issued in error caused the policy to be cancelled with the incorrect date. The proper corrections have been made which will allow for his policy to be terminated effective December 31, 2015. We apologize for and regret any frustration *** *** experienced during the resolution of this issue. Coventry does not report unpaid accounts to the agencies that maintain credit reports so his credit will not be affected. However, our systems will be updated to correctly reflect that his policy was terminated by the Marketplace at *** ***’s request, rather than showing cancelled for nonpaymentWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com Regards, Chris B*** Complaints and Appeals Consultant Executive Resolution Team

Dear
*** ***,
Please
see our response to complaint #***
for *** *** that was received by us on February 22,
During
our review, it was determined that the letter *** *** 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*** *** 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 *** ***We take customer complaints very seriously and
appreciate you taking the time to contact us and giving us the opportunity to
address *** ***’s concerns. If there are any additional
questions regarding this particular matter, please contact the Executive
Resolution Team at ***@***.com
Regards,
Julian
C***
Executive
Resolution Team

Dear
*** ***,
"Times New Roman"">Please
see our response to complaint #*** for *** *** that was received by us on April 8,
In
reviewing *** ***’s complaint, we were unable to locate any current policies
that she has through Coventry Health Care or *** or any recent phone calls
that had been made to her. As such, we
were unable to determine who had attempted to contact her or why no one spoke
when she answered. Her name and
telephone number have been added to our Do Not Call Registry, which will
prevent any unsolicited telemarketing calls from being originated by *** or Coventry
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address *** ***’s concerns.
If there are any additional questions regarding this particular matter, please
contact the Executive Resolution Team at ***@***.com
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear
*** ***,
Please
see our response to complaint #***
for *** *** that was received by us on January 25,
After
reviewing the complaint and *** ***’s claim history, we did locate two claims
that had been denied by Coventry that fit the situation he
described. The claims were both for the same diagnostic
test but were from different providers.
One provider was billing for the technical component of the test and the
other was billing for the professional component. Both claims were initially denied as our
out-of-network fee schedules had not been set up allow them. The processing guidelines have since been
updated so we were able to have them reprocessed to overturn the denials
While
the claims were adjusted and allowed, *** *** is responsible for the entire
billed amount as everything was either applied towards his out-of-network
deductible or was above the amount we recognize as an eligible medical expense
for the services performed. If he
wishes, *** *** is able to appeal the out-of-network determination by sending
a written appeal request to *** Health Plans, Appeals Department, *** *** *** *** *** *** South Jordan, Utah, ***-***. Appeal requests can also be e-mailed to ***@cvty.com. Explanations of Benefits for each claim will
be mailed out to *** *** that give the specific processing details as well as
the information about submitting appeals
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address *** ***’s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at ***@***.com
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team

From: *** ***Date: Wed, Nov 9, at 5:AMSubject: Coventry Health Care, IncYour complaint was assigned ID ***To: [email protected] Health Care, Inc.. Your complaint was assigned ID ***This was resolved on 11-8-with the business.Thank you*** ***

Dear
Ms***,
"Times New Roman"">Please
see our response to complaint #***
for ***
*** that was received by us on April 4,
Upon
receipt of the complaint, our review showed that Mr*** had two active
policies with Coventry. This occurred
due to a policy applied for through the Federal Health Insurance Marketplace
for being automatically renewed for and a separate enrollment notice
being received from the Marketplace for coverage in 2015. Both policies were set up to have the
premiums collected automatically through recurring Electronic Funds Transfers
(EFT). As we did not receive a
termination notice for either policy and payments were being received for each,
both polices remained active, both were renewed for 2016, and an EFT was
performed for both policies for each month of coverage going back to January
We
were able to have the policy that had been automatically renewed for
terminated back to December 31, 2014.
This allowed us to move all payments received for that policy for
and to the other policy that remains active and issue a refund for a
portion of the payments we had received.
A refund in the amount of $was deposited directly into his bank
account on or around April 8, 2016. The
bank account information has now been removed from both policies which will
prevent any future payments from being collected unless the bank account
information is provided by Mr*** again.
Mr
*** had also said that he wishes to cancel all coverage with Coventry as of
March 31, 2016, due to obtaining other coverage. We have reviewed all information received
from the Marketplace and have determined that we have not received the proper
notification from the Marketplace that would allow us to grant that termination
date. We called Mr*** in an attempt
to perform a conference call with him and the Marketplace to advise them of
what is needed, but Mr*** refused.
As the Marketplace will not speak with us without authorization from the
applicant, we are unable to assist further on that part of his request at this
time. If Mr*** would like help with
the termination in the future, he may call me directly at ###-###-#### and the
conference call can be performed
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Mr***’s
concerns. If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at ***
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team

Dear *** *** Please see our response to complaint #*** for *** *** that was received by us on January 6, 2018. 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
*** *** did not provide her mother’s name, so we were unable to fully confirm the policy affected. We attempted to speak with *** *** over the phone at the number provided, but our calls were not answered or returned. In order to pursue the issue, *** *** 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 *** *** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *** Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team

Dear
*** ***,
"">Please see our response to complaint
#*** for *** *** that was received by us on February 4,
Upon receiving the complaint, we noted
that our Billing and Enrollment department had already begun the process of
correcting the issue that led to *** ***’s policy not activating after the
first month’s premium payment was received.
Unfortunately, we were not able to meet the hour deadline he had
requested but the system has now been updated to show his policy active with an
effective date of February 1, 2016. We
have been in contact with *** *** and advised him of this resolution.
We take customer complaints very
seriously and appreciate you taking the time to contact us and giving us the
opportunity to address *** ***’s concerns. If there are any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at ***@***.com
Regards,
Chris B***
Complaints and Appeals Consultant
Executive Resolution Team