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 Administratively Resolved]
Complaint: ***
I am rejecting this response because:
To say that my father did not require skilled care when he came is incorrectHe required full-time care which I had to provide in my home because there was no other place for him to go, and since he was rejected by Medicare, *** *** couldn't even provide the care if we paid for it ourselvesThat meant I had to take unpaid time off from my job, since I do not have paid medical leaveto care for my father full-timeEven doing that, within the month, we had to readmit him to the hospital because of ongoing problems with cdiff, kidney disease, and congestive heart failure, all issues he had when he was released from *** ***He is now at *** *** Hospital receiving care to address further kidney damage he developed here at home under my care because of diarrhea that had never cleared up and that steadily worsenedHis kidneys are now so severely damaged he has been in the hospital for more than a week and they still do not know when or if he will ever be able to live independentlySo, no, I do not accept that he was ready to "go home" when he was delivered to me from *** ***I do not accept that he did not require full-time skilled care, because I gave him full-time unskilled care here at home as best I could along with visiting nursing and rehab, and he never really recovered and ended up even worseSo, no, this is not sufficient, and no, I do not accept itIn fact, it has cost my family income that I cannot recover as I provided the care he should have received at *** ***It has cost my family being exposed to cdiff as his condition worsened, and I have two children here at home and a Type I diabetic husband who is vulnerable to infectionAnd it has cost my father his quality of life and now potentially his life as his kidneys and heart have been damaged even furtherThe only reason I'm not suing is because an year old man has no economic value on this earthHe is, apart from his SS income and pension check, an economic washSo nobody caresSo congratulations, CoventryAnother case "managed."
*** ***

Dear *** *** ***: Please see our response to complaint #*** for *** *** that was received by us on August 10, 2016. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon 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 *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com. Sincerely, Ashley W.Complaint and Appeals ConsultantExecutive 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: 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,
*** ***

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:When I informed a customer agent about a closed account, she assured me there would be no issues.  Also, the website itself is a bit ambiguous about how a payment should be made and what happens if a payment is rejected.  A customer should not be charged additionally because they were confused about how to change payment type.  After researching the website thoroughly, I am much more adept in navigating the website regarding payments.   I am just very upset I was charged $40.00 for fees because of this confusion.  From now on, I will either call or mail my payment to avoid any confusion.  This is bad customer service, considering I work with customers on a daily basis five times a week, and I have never encountered a time when there is no SUPERVISOR on duty. 
Regards,
[redacted] Jr

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on January 18, 2018.  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 our Billing and Enrollment department for investigation.  It was confirmed that the premium payments collected for the policy are correct.  [redacted]’s policy has an effective date of January 1, 2016, and a termination date of December 31, 2017.  The total of premiums owed for the period of active coverage was $12025.76, which is equal to the amount that has been collected from [redacted] since her coverage began.   Since there is no overage of the premiums collected for the policy, no refund is due.  We were also advised that the premium for January 2016, had previously been removed from her policy and was not collected initially.  This was due to improper handling of a complaint that had been submitted through the Federal Health insurance Marketplace (FHIM).  When the error was discovered it was corrected, and an Electronic Funds Transfers was scheduled to collect the amount owed.  A notice dated December 19, 2017, was sent advising that the remaining amount owed of $412.59 was to be collected on January 2, 2018.  We also asked if the effective date for the policy could be changed to February 1, 2016, so that the January 2016 premium would no longer owed and the payment could be refunded.  We were advised that the electronic files received from FHIM indicated that the effective date for coverage was to be January 1, 2016, so additional changes can’t be made unless updated files are received.  We regret any frustration or inconvenience 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 [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. 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, 2015.
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

Dear
[redacted],
Please
see our response to complaint #[redacted]
for [redacted] that was received by us on October 16, 2015.
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 $2500 for any individual person
or $7500 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]@[redacted].com.
 
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

Complaint: [redacted]
I am rejecting this response because:
------- Forwarded message ----------From: Revdex.com of Metro Washington DCDate: Mon, Feb 22, 2016 at 8:50 AMSubject: Fwd: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #[redacted].To: [redacted]@myRevdex.com.org---------- Forwarded message ----------From: [redacted].com Date: Sat, Feb 20, 2016 at 10:26 AMSubject: Re: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint #[redacted].To: Revdex.com  Thank you for your follow up letter.  Everything looked like it had been resolved until I received a bill in wednesday february 17th in which coventry states tgat they will deduct my premium if 161.58 from my bank account on february 29th.  This is nit the correct premium (as they clearly state in their response letter above).  The correct premium is 123.18. This will again result in me being charged two premiums.  How is it that their accounting deoartment find it impossible to bill for the correct amount.  In addition they clearly state that the over charges resulted in numerous policies beibg open which they resolved.  Obviously not because im beibg billed again for the same open policy.  Can u please try and have then resolve this for the 5th time.  Thank you.  Sent from my [redacted] 4G [redacted] device
Regards,
[redacted]

Dear [redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on June 15, 2015.
During our review, it was determined that the member’s initial binder payment was made May 30, 2015. This posted to the policy on June 01, 2015. I confirmed with our...

Billing and Enrollment department that the member’s ID card was sent on June 02, 2015.
When a binder payment is posted it can take about 7-10 business days for member’s to receive their ID cards in the mail. An update from the Marketplace was received on June 10, 2015, terminating the member’s coverage effective June 25, 2015. The member’s final bill and a refund for the remaining 5 days of the month will be refunded within 7-10 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

Dear [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on enter complaint received date. 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 Billing and Enrollment department to have the member’s concerns reviewed. We were advised that they are currently reviewing the complete history of payment’s on file for the member. We are still in the process of reviewing the history so that we may provide the member with the complete refund he is owed. We sincerely apologize this is taking longer than expected but we want to be sure the member gets the full refund owed. We 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 W. Complaint 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 reimbursement. We
were able to locate the reimbursement request and were able to have it
processed for the reimbursement. The check was mailed to the member’s home
address yesterday, February 17, 2016. We apologize for providing the incorrect
form in the original response. If 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 concerns. If you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
 
Thank you,
Ashley S.
Complaint and Appeal 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 our Eligibility department to...

verify that the member’s coverage was active and we had the correct requested termination date on file. We confirmed the member’s policy is still active and paid through the end of the month. The Marketplace file we have received shows a future termination of September 30, 2015.
We confirmed with our Claims and Benefits department the member has the ability to submit his claims until September 30, 2015. Please have the member re submit any claims they may have and reach out to the Claims and Benefits department at ###-###-#### for reimbursement for any out of pocket expenses.
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.
 
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 December 1, 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 our Enrollment department for investigation.  It was noted that [redacted]’s policy was active in our medical claims system, but was not showing active in our prescription claims system.  At that time, the prescription coverage was manually reactivated and additional research was done to determine what was causing the issue.  A system set up issue was subsequently identified and corrected.  Our management team reviewed [redacted]’s request for a settlement or credit, and determined that no premium refund will be issued.  However, the attached form can be used to submit requests for reimbursement for any prescription expenses he paid for.  Any submitted claims will be processed according to the terms of his policy. We regret any frustration or inconvenience [redacted] experienced as a result of 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. 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 23, 2018.  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 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 31st. All unused points will expire on December 31st of each year. We 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 $15 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 offered. 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]@[redacted].com. Regards, Chris B. Complaints and Appeals Consultant Executive Resolution Team

Dear [redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on August 21, 2015.
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] [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 normal 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 account. Technicians 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, 2015.
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]@[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 November 30, 2015.
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 Mr. Khattak’s
concerns.  If there are any additional questions regarding this particular
matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
 
Regards,
Chris
B[redacted]
Complaints
and Appeals Consultant
Executive
Resolution Team

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.  Thank you so much!
[redacted]
[redacted]

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I was not contacted by a Representative  about another policy, However I did call and apparently a policy was started on 2/26 that I didn't approve of.Also a payment for January was pulled out of my acct on 3/5 for January when OCT, NOV, And Dec my automatic draft didn't seem to work and I had to call and make payments, it magically works now, and When I called 3 times and no payments were due and in February spole with Tisha and Neina and they said I had no payments due through March 31st when yall were canceling my policy. and now  that I have reported yall, yall just decided to start pulling money out of my checking account that this whole time yall didn't show it worked... I will be contacting the insurance commissioner today because I called about the payment yall pulled out on march 5 and it being for January now means that yall are just going to pull the other 2 months (that wasn't able to be paid when they were due bc yall had no record of a payment due) in april and may when I no longer have coverage from yall and am paying on a new policy IF I am able to get one since all this didn't get handled til after open enrollment when I called about the letter prior and there was no problem with my acct per Latoya
Regards,
Kristen M[redacted]

Dear
[redacted]
Please
see our response to complaint #[redacted] for [redacted] that was received by us on October 6, 2015.
During
our review, we found that [redacted] was covered on our SIL 3 $5 CPPO METRO
MO plan beginning on December 1, 2015.  The
policy was...

passively renewed and she was moved to the SIL 73 $5 CPPO 2750 MO
plan effective January 1, 2015.  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
2014 was $110.49.  The amount increased
to $139.90 with the plan for 2015.
We
were able to locate a renewal notice that was sent to her that stated the new
amount for 2015 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 30 day supply of a
medication.  The denial was applied because
her plan requires that fills for more than a 30 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 refill. Our 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, 2015. 
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 $139.90 for
the premium for October 2015 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 $4.51 for
each day of coverage in that month. 
Since the policy was active for only one day, she was only responsible
for $4.51 and the remaining $135.39 that had been collected was refunded
directly into the bank account on record with an estimated posting date of
October 8, 2015.
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],
"Times New Roman"">Please
see our response to complaint #[redacted] for [redacted] that was received by us on February 18,
Upon
receiving the complaint we immediately reached out to our Billing and
Enrollment department. We were able to have
the policy cancelled back to December 31, 2015, and our system is showing $
owed with a paid thru date of December 31,
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