Clark Insurance

Dear
*** ***,
Please
see our response to complaint #*** for *** ***
that was received by us on January 15,
In
researching *** ***’s complaint, it was noted that the application we had
received for her policy did request a November 1, 2015, effective date.
When the application was first received and
reviewed, it was determined that additional supporting documentation needed to
be provided to activate the policy. The
supporting documentation needed was proof of a qualifying event that would
allow for a midyear effective date.
Proof of termination of other insurance coverage was received in
December and the policy was activated at that time, retroactive to November 1,
2015. When the policy was activated, the
November premium was drafted. We made a request with our Underwriting department to change the effective date of the policy to December 1, 2015. The request was granted. This allows the premium that she paid for the month of November to be credited back to her. Rather than issue a refund, we will apply the credit towards her February premium which will reduce the amount she has to pay for that month
Ms
Erb’s premium increased as of January 1, 2016, since all individual policies
are subject to be re-rated the first of every year. A notice was sent to *** *** regarding the
increase but due to the short turnaround time in between the activation of the
policy and the end of the year, she may not have received the notice in time to
read it and become aware of the change.
A letter was also sent advising her that the next premium withdrawal
would be for an increased amount in order to collect the premium for December
and the higher amount for January.
Again, with the shortened timeframes, she most likely would not have
received the adjusted premium withdrawal notice in time to deposit the required
funds into her account or cancel the scheduled withdrawal
Finally,
in order to determine if we will issue reimbursement of any overdraft fees,
Coventry requires bank statements supporting the amount of the fees. We spoke with *** *** over the phone and
requested those bank statements. They
have been received and will be forwarded to the appropriate area for
review. We will notify her directly of
the outcome of that review. 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

Dear
*** ***,
"Times New Roman"">Please
see our response to complaint #***
for *** *** that was received by us on March 14,
In
reviewing the main complaint regarding the tax form, we were able to confirm
that the 1095-A form he is seeking is provided by the Federal Health Insurance
Marketplace. This means we are unable to
send the form to him directly.
We
also investigated the second part of the complaint regarding non-response to a
Markeplace escalation. Health Insurance
Casework System (HICS) cases are the way that the Marketplace tracks and
reviews those escalation requests. They forward
cases to the associated health insurance carrier if an issue requires something
from the carrier. We reviewed all areas
that Coventry has been granted access to within HICS but found that no
escalations for *** *** were sent to us in 2016. As such, we are unaware of what additional
information the Marketplace may need from us prior to sending the form
It
was noted that *** *** had the intention of ending his coverage through
the Marketplace in 2015, but an enrollment file with a termination date was not
received by Coventry. While we did not
receive premium payments for November or December, the grace period guideline
for members receiving an Advanced Premium Tax Credit states to keep the policy
active for at least days and to then terminate the policy back to the end of
the first month of nonpayment. The
policy was recently terminated back to November 30, 2015, in accordance with
that guideline. The termination date is
communicated back to the Marketplace through an enrollment reconciliation
process. The completion of that process
may facilitate the 1095-A form being sent out
We
have been in contact with *** *** and the Marketplace and will continue
to offer all possible assistance in getting the Marketplace to send out the
form. We regret any frustration he has
experienced in seeking a resolution for this issue.
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 November 9,
We are
showing that *** *** was covered by a plan named *** *** through
Coventry Health Care of Georgia beginning on January 11,
2012. The application for that plan was not done
through the Marketplace. The plan was no
longer offered as of December 31, 2014, so the policy passively renewed to a
new plan named Bronze $Copay HMO PD effective January 1, 2015.
A termination request was not received for that policy and the recurring
Electronic Funds Transfer (EFT) draft authorization had not been removed so the
premium was drafted for January and February.
We regret that the renewal notice *** *** was sent in did
not mention that a termination request would need to be sent to prevent the
passive renewal even if a new policy was applied for
As *** *** applied for a new policy through the Marketplace that became
effective January 1, 2015, we were able to have the non-Marketplace policy
terminated effective December 31, 2014.
A refund of $was issued through the EFT process directly into the
bank account from which the payments had been collectedThe approximate
posting date for the deposit was November 13,
At this
time, we are showing that *** ***’s policy has a termination date
of December 31, 2015, so as long as the premium is paid for December, her
coverage will remain active through the end of the year. Information was received from the Marketplace
to enroll her on a different policy effective January 1, 2016. The first month’s premium payment will need
to be made for that policy to complete the activation process
We were
not able to locate a call to Coventry such as the interaction *** ***
described regarding the November 30, 2015, termination date. All termination requests need to be requested
through the Marketplace so she may have been speaking with them. If she wishes, we can assist in contacting
the Marketplace to report the poor service she received
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 #*** for *** *** that was received by us on December 9, 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 reached
out to our Billing and Enrollment department. It was found that several refund checks were sent to the address on file for our member, Mr***’s father, which is in Florida. We requested that the refunds that had been sent to that address be reissued. The Billing and Enrollment department processed the refunds, but since the initial payments were drafted through Electronic Funds Transfer (EFT) the refunds were inadvertently issued through the same method automatically. This led to EFT transactions being performed to transfer the funds back to the account the payments were collected from. At this time, we are continuing the monitor the situation. If the EFT transactions are rejected, as would be the case if the bank account used is now closed, we will reinitiate the refund requests and ensure they are sent to Mr***’s address in Maryland. If he has questions or concerns in the meantime, he may contact me directly by phone at ###-###-#### or by e-mail at ***We apologize for and regret the frustration and inconvenience he has experienced in getting this issue resolvedWe 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 Ms*** ***: Please see our response to complaint #*** for *** *** that was received by us on January 10, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the rejected response, we contacted our Customer Service team to address the complainant's concernsWe confirmed that *** *** *** is not directly affiliated with ***, Coventry Health Care, or *** ***Our relationship with *** *** *** is only through a provider network rental agreement that they have with *** ***The agreement allows their membership to visit providers who are contracted with *** *** and receive discounted rates for servicesWe reviewed the health card and it states for Billing & Cancellation, that HII Insurance Solutions should be contacted for Billing and CancellationThe phone number is listed as ***Mr*** would need to contact that company for resolutionAlso *** *** is not listed as the claims broker. According to the card, the claim administrator is Administrative Concepts IncThe phone number listed on the card is ***. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at s034590@***.comSincerely,LaShonda C.Complaint and Appeal 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 Administratively Resolved]
Complaint: ***
I am rejecting this response because: Again I was told after beginning treatment as the inital claims were revived and processed after treatment began August of with the inital set of X-raysI am asking as before to hold them responsible as what they relay to patient via email, telephone and online as being falseAs clearly seen in pictures I emailed coverage online was indicated and verbally given to Diane August In phone conversions which you fail to mention it was confirmed the information given was falseHowever treatment had already beganLook back in your so called phone records and you will see a conversation that the representative does admit to falsely go ring information to Doctors officeWhether or not I called about it is irrelevant as Diane from Doctors office was told I had coverage on the August conversationAlso I would like to address the information of the website telling their patients who is in and out of networkI would like to be compensated for that as wellIf I have to involve my lawyer *** *** from *** I guess that's the next stepAlso I will be contacting the local newspaper and TV stations to try to get my message across
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 youAs previously stated, we researched the member’s call history and found a call from the member on August 14, 2014, where the orthodontic coverage was provided stating that coverage was only for dependent children under the age of The customer service representative also emailed the member’s benefits to her; which stated the same thing, orthodontic coverage is eligible only for children under the age of The member did not have the braces placed until October 09, 2014, giving her two months to cancel the services with the provider, knowing the plan did not cover the services that were to be renderedAt this time we will not be covering the orthodontic claim as the member was provided the correct benefit information over the phone prior to the braces being placed, as well as having the benefit packet emailed to herWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’ concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.comThank you, Ashley SComplaint and Appeal 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: ***
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 2016.
Regards,
*** ***

Dear
*** ***,
Please
see our response to complaint #*** for *** *** that was received by us on February 19,
During
our review, we reached out to our Billing and Enrollment department who were
able to verify that the policy has been reviewed and
adjustments
have been made to the policyThe member’s premium from February
through May was $28.09; for the month of June and July the premium was $
giving a total amount of $total billed for the life of the policy
The
member made total payments in the amount of $1,leaving the remainder of
$1,The refund in the amount of $1,was approved on February 25,
and will be reimbursed within 24-hours to the member’s ***
accountIn addition the member was notified of the Advance
Premium Tax Credit (APTC) change and draft changes in two different letters
sent on August 14, and September 15,
I
apologize for the frustrations and difficulties *** *** encountered while
attempting to resolve this issue and regret that this matter required much of her
time in order to facilitate a resolutionUnfortunately, we are unable to honor
*** ***’s request for compensation
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 Ms***: Please see our response to complaint #*** for *** *** that was received by us on December 30, 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 systems and confirmed that Ms***’s policy was applied for through the Federal Health Insurance Marketplace (FHIM). With these policies, Coventry Health Care is unable to make changes to an applicant’s coverage unless the FHIM sends specific direction telling us to do so.We reviewed the communications sent to us by the FHIM and have noted that we have not received a notification advising to remove Ms***’s daughter from her policy. Also, we have correctly processed all the notifications regarding the premiums owed, the benefit plan, and the Advanced Premium Tax Credit for Ms***Due to this, her daughter remains covered on her policy from the start date of the policy, March 1, 2015, to the end date, December 31, 2016, when we stopped offering plans through the FHIM in the state of Florida. We recognize that this is not Ms***’s desired outcome. However, we are correctly following the established FHIM regulations in this decision. If Ms***’s daughter has additional coverage for 2016, claims processed by Coventry may be able to be filed to the secondary carrier to determine if additional payment can be made. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms***’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 Ms***, Please see our response to complaint #*** for *** *** that was received by us on May 12, Upon receipt of the complaint, we immediately reached out to our Billing and Enrollment department. It was found that Ms***’s policy was affected by a known
issue where bank drafts were attempted to collect premiums multiple times in early April. The issue was corrected quickly and the multiple drafts were reversed. However, it seems that Ms*** was given misinformation by her bank in that they stated we had only reversed seven of the eight drafts attempted instead of reversing all of them A Billing and Enrollment representative was able to perform a conference call with Ms*** and her bank and it was found that we had indeed reversed all of the attempted transactions. At that time a payment was also scheduled which brought the policy current through its period of active coverage which ends May 10, 2016. The May 10, 2016, end date for the policy was the date sent to us by the Federal Health Insurance Marketplace after Ms*** contacted them on April 26, We apologize for and regret any frustration Ms*** experienced in her contacts with our Customer Service department during her attempts to resolve her issue. All complaints are documented and reviewed by leadership as part of our ongoing efforts to determine any areas where improvements are needed in regards to the service we provideWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms***’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

[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 February 05,
During our review, we reached out to our Medicare department to review*** *** was contacted by our Medicare department to discuss and address her concernsIt was
confirmed with the member that the medication in question is a Tier medicationOn the *** *** Part D Value Plus plan, the member pays a 50% coinsurance of the negotiated rate for a Tier medication when filled at a network pharmacy during the Initial Coverage Stage*** *** was advised that the negotiated rate can vary and that impacts the cost of her medicationMany factors can lead to a change in priceAdvised the member that all prices provided are estimated amounts and that actual benefits are determined at the time a claim is submitted and may be impacted based on the benefit stage
Informed the member the cost has updated online and can again change if the cost changesThis is the reason for only being able to provide estimates, as each pharmacy can have its own negotiated rateOffered additional assistance, the member declined stating she does not qualifySuggested other lower cost alternative and the member stated she can’t take anything else
Advised the member on tiering exception - A tier exception is a request to lower the cost-share responsibility of a drug contained in the non-preferred brand tierBefore requesting a tier exception, we advised she consult with her doctor to ensure that she has not had success with drugs already listed in the preferred tiersAdvised that medical documentation will be required showing that these alternatives have not been successful before her request can be considered
Informed the member she or her doctor can ask the plan to consider a tier exception by calling our Coverage Review department at ###-###-####Reminded the member clinical information and supporting documentation may be required for the plan to make a well informed decisionThe turnaround time for a standard coverage determination is hours and hours for expedited requestsAdvised once the plan has made a decision she will be informed
Advised the member that the “Your Plan Results” on Medicare.gov shows ranges of Copay/Coinsurance of $1-$47, 33%-50% for the FH Value Plus planAlso advised the member when selecting the “View Drug Benefit Summary” tab under the “Drug Coverage Information” section in the *** *** Value Plus plan information the Summary provides a list of cost-share at Preferred and Standard Pharmacy’s during the ICL for 30, and days
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 June 16,
We are unable to conduct our review with the information provided. We could not locate the member’s record without a name or a policy numberIn addition
if, under applicable law, an executor, administrator or other person has authority to act on behalf of a deceased individual or of a deceased individual's estate, we are permitted to treat such authorized person as the personal representative of the deceased. As such, *** *** would need to submit the appropriate documentation to show she is legally authorized to act on behalf of her deceased mother before we can review her request
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

[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. However, there still appears to be a discrepancy in the amount owed to me from the providerI hope Coventry can resolve this matter expeditiously
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 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 *** ***’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 July 27,
We show that *** *** and his spouse were enrolled on the Gold $Copay plan with Coventry Health Care of Missouri through the Federal Marketplace effective
January 1, 2015, to April 30, 2015. The initial enrollment file we received from the Marketplace on December 4, 2014, set the Advanced Premium Tax Credit (APTC) for the policy at $1158. This left the remainder of the premium, $834.50, as the portion for *** *** to pay. All premiums were paid for January through April
On April 9, 2015, a new file was received from the Marketplace that removed the APTC from the policy effective May 1, 2015. This meant that the entire premium, $1992.50, needed to be paid by *** *** by May 31, 2015, to keep the coverage active. A payment was received for a portion of the May premium, $834.50, on April 24, 2015. Since that was not enough to cover the entire premium, the policy was terminated back to April 30, 2015. The payment that was received for the May premium was refunded to *** *** on a paper check on June 19, 2015.
*** *** may contact the Marketplace appeals department at ###-###-#### to have them review the APTCThe Marketplace would need to submit a new file to update or correct the APTC if an error is found
On all the enrollment files Coventry received from the Marketplace, we were given *** ***’s physical address. The Past Due and Cancellation letters were sent to that address. Coventry is required to use only the address provided by the Marketplace for the plans applied for through them. A previous application for a non-Marketplace policy that we had received for *** *** had a P.OBox address but that policy was never instated.
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 #*** for *** *** that was received by us on February 23, 2016.In reviewing the prescription claim history for the policy that covered Mrs*** 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*** 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 criteria. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs***’ concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***.Regards, Chris B***Complaints and Appeals ConsultantExecutive Resolution Team

Dear
MsCameron,
Please
see our response to complaint #***
for *** ***
that was received by us on March 09,
During
our review, we reached out to our Customer Service department to verify the
calls once again
It was confirmed after the calls review,
that the member was advised that for this type of procedure a Prior
Authorization would be required and would need to be approved in order for
there to be any benefits providedDuring review of the service, as previously
advised, first and second level appeals were performed asking for coverage for
the procedure, but the decision to not allow coverage was upheld in both cases,
as the procedure in question is specifically excluded
from coverage in this member’s policyThe calls review did not indicate any
incorrect information being provided to the member
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 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 *** ***: Please see our response below to the additional concerns reported in complaint # *** for *** *** that were received by us on July 12, Upon receipt of *** ***’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 *** ***’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, 2016. Once those updates were made, we contacted *** *** 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 *** *** when they are finishedWe apologize for and regret the frustration *** *** 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 *** ***’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.comSincerely, Chris B***Complaints and Appeals Consultant Executive Resolution Team