Cookworks, Inc.

Upon review of the members complaint, we confirmed the policy is terminated and there are no claims on fileWe have issued a refund of $for the total amount of premiums receivedThe member will receive two refunds; one in the amount of $27.40, issued on 08/10/The second refund, for
the remaining balance of $319.74, issued on 08/18/

[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,
*** ***

Per the complainant’s request, a representative from
CareFirst’s Medical Customer Service Department contacted *** *** to
discuss the concerns he had with medical expenses*** *** was advised the
claim he was questioning had been paidA duplicate explanation of benefit
(EOB) was
forwarded to *** *** to reflect the payment detailsDuring the
contact, *** *** requested that someone from the CareFirst Dental Business
Office email him regarding his concerns with outstanding dental expensesIt
appears the issue regarding outstanding medical expenses has been resolved accordingly
As requested, a representative from CareFirst’s Dental
Customer Department emailed *** *** to discuss his concerns*** *** replied
to the email by asking the representative if he could follow up the next dayThe
representative reached out to *** *** on 12/03/as he requested in the
email, but he never respondedTo date, no additional contact has been made by
*** ***Several voice mail and email messages have been sent to *** *** requesting follcontactUntil contact is made with *** ***
to discuss his concerns with outstanding dental expenses, the issue cannot be
resolved
For your information, *** *** did not relay any
concerns with vision expenses during the contact that was made thus far by
CareFirst

To Whom It May Concern:We have received your complaint. In order to properly research the issue at hand we will need the member's ID number, date-of-birth and the dates-of-service in question. Once the requested information has be received we will open and investigation and respond
directly to the complainant only.Thanking you in advance,Brian * K***, PAHMCareFirst BlueCross BlueShieldSenior Regulatory Analyst|Executive Inquiry***@carefirst.com

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to meI look forward to hearing from them regarding DC Healthlink's response.
Regards,
*** ***

CareFirst has contacted the member and advised that an error occurred with billing as her daughter was removed from the policy on 9/24/(with retro termination date 6/30/15)The billing has been corrected and was updated on 12/01/2015. The member was
credited a total of
$(294.27x5=$1471.35) which was the difference
between the old rate of $and the new rate of $for the coverage
months of July -Nov (1807.68-1513.41=294.27). The member currently has a
balance due for the coverage month of December for $42.06. Billing
invoice attached

CareFirst contacted the member, *** ***, on 12/and was advised that her complaint is against *** *** Hospital*** *** advised CareFirst that she contacted the hospital regarding her need for physical therapy and she was advised that the hospital had contacted CareFirst regarding
her visits and she would be responsible for $per sessionShe agreed to pay the $per session and said she refuses to pay the hospital more than they told her she would have to payCareFirst asked if the member contacted CareFirst Customer Service for a physical therapy benefits quote, and she stated she did not; she only contacted the hospitalThe member advised CareFirst that she filed the Revdex.com complaint against CareFirst and the hospital because she did not know how to get the issue resolvedCareFirst advised the member of her benefits (quoted below) and offered to contact the hospital on her behalf to be of any assistance possibleCareFirst also advised the member that this is not a standard practice, but we will try to help resolved her issue CareFirst Representative Quoted: “In Network:[In-Network Physical Therapy benefits were quoted and member was informed of her individual and family (H.S.Aincluded) deductible that must be met before 100% coinsurance would apply also quoted the following:] The benefit for In-network Facility-Outpatient is considered; deductible applies, authorization not required, referral not required, Copay: $Per Day Per Provider, then coinsurance considered at 100% of the CareFirst allowance , limited up to Visits within calendar year from 01/01-12/31.” CareFirst spoke with *** *** in *** *** Hospital billing on 12/29/and she stated, *** *** called the hospital on 03/11/to advise them she has a $9,deductible, $copay, visits limit, and coinsurance considered at 100% of CareFirst allowance. *** *** stated that *** *** called them to offer this information regarding her benefits and this is what they have notated in their system under her account CareFirst sent an email to *** *** on 12/29/to advise her of the conversation with *** *** at *** *** Hospital billing and to inform her of what MsMorris had stated was notated in their system under her accountCareFirst advised *** *** she may follwith the *** *** Hospital billing Manager, or email the billing department at: billing@***.org to dispute the charges based on what she indicated she was told

Please be advised we are still activily working with the DC Healthlink (DCH) concerning the members complaint/ refund requestWe will be able to provide next steps upon the completion of DCH's review; at this time, there is nothing more he needs to do

CareFirst has conducted a complete review of files received for the members account and has determined that the member has been billed correctlyThe members monthly amounts owed are outlined below, along with application dates and other pertinent information that should assist in clarifying this matter1/30/- New Application was received with a 3/1/effective date; $monthly rate, $APTC amount and $member monthly owed amount 5/20/- Subsequent Application was received with a 6/1/effective date; $monthly rate, $APTC amount and $member monthly owed amount 6/26/- Subsequent Application was received with a 7/1/effective date; $monthly rate, $APTC amount and $member monthly owed amount Based on information CareFirst has received from the Maryland Health Exchange, the members subsidy has changedThe member will need to speak with the Maryland Health Exchange if she is in dispute of the subsidy amount and/or effective date of any changes submitted on her policy

[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: I've attached my insurance card in this response due to the accusation of me not being insured by that company.Please let me know if you have any further questions for me
Regards,
*** ***

CareFirst BlueCross BlueShield is unable find the member with the name or account number provided.  The prefix [redacted] is not a prefix used for products sold by CareFirst. [redacted] lists her address as Chicago Illinois. As an out of state resident, she would not be eligible to purchase a plan...

from the Maryland Health Connection  (Healthcare Exchange). You need to be a resident of Maryland to obtain an  individual or family coverage through Maryland Health Connection. Please see their website www.maryland healthconnection.gov

As requested, contact was made to [redacted] to discuss the Group’s inquiry to your office and past billing problems.  It was confirmed that there were at least two (2) instances in the past 6 months where payments submitted by the Group were improperly applied. In both cases the payments...

were located and posted after the group contacted us. To mitigate the potential risk of future issues, these examples were sent to the appropriate departments for possible process improvements and technical solutions. Arrangements were made with the Group to forward all future payments to one designated contact person for special handling. Once the issues with payment posting have been corrected and the Group’s confidence has been restored we will work to reintroduce the normal payment submission process with them accordingly.

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

A termination request, effective 01/01/16, was received from the Exchange on 12/21/15 and that request for termination was processed on the same day, 12/21/15.
A refund of $214.53 was processed on 01/04/16.

[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 as Answered]
 Complaint: [redacted]
I am rejecting this response because:From: [redacted]<[redacted]@[redacted].net>Date: Wed, Mar 15, 2017 at 11:06 AMSubject: Re: cid [redacted] / Care First BlueCross BlueShieldCarefirst has not resolved my complaint.  I have sent Mr. K[redacted] the documents that he requested on February 15, 2017.  Please reopen this case.Thank you,[redacted]  K[redacted], Brian wrote:Good Morning [redacted]- As I advised in my last email, [redacted] is a self-insured account.  For this reason it up to the group to determine how to handle the situation at hand.  Your problem has been presented to the [redacted] representative and we are now waiting for their decision.Brian *. K[redacted], PAHMCareFirst BlueCross BlueShieldSenior Regulatory Analyst|Executive InquiryMail Stop [redacted]1501 S. Clinton StreetBaltimore, MD 21224www.carefirst.com
Regards,
[redacted]

[redacted] submitted a ‘Notice About Medical Assistance' to CareFirst as proof of other insurance effective 4/1/2016. The member's policy with CareFirst terminated for non-payment of March's premium; the policy has a 3/31/2016 termination date.[redacted]s eligible for reinstatement but in...

order to bring the policy current and be paid in full thru 7/31/2016, he will need to pay $1,449.19 ($773.59 for the month of March + 4 x $168.90 for the months of April-July) since the effective date to remove the dependents is after the 3/31/2016 termination date.If payment is made and the policy is reinstated, the dependents can be removed effective 3/31/2016 and the policy will become a Self Only policy.CareFirst spoke with [redacted] on today, 6/29/2016, and he advised that he will make the payment of $1,449.19 on Friday, 7/1/2016.[redacted] asked if all of his will be reimbursed and CareFirst advised that we are unable to guarantee any payment of claims; however, we will consider them through processing according to his contractedbenefits,[redacted] agreed that he feels we are headed in the right direction for resolving his concern and there is nothing further he needs assistance with at this time.

The member had dual enrollment with CareFirst for on exchange and group coverage from 8/1/16 to through 8/1/17. CareFirst did not speak with the member until 9/11/17 to discuss refund of payment made for the month of August 2017; the members on exchange coverage was already terminated. This case is...

currently with DC Healthlink to confirm the members call history on their end.

[redacted] will need to contact the Exchange to discuss subsidy changes. A member of our CareFirst Service Team has made an attempt to contact [redacted] via telephone to advise her of this; however, she was not available and a voicemail message was left including a direct phone number for the member...

to return the call. Additionally, an email message was sent to the [redacted] to inform her that she will have to refer back to the Exchange for assistance.

The [redacted] confirmed the member contacted them on 9/14/2017 to request a termination and has agreed to submit the records terminating the member’s dental policy effective 9/30/17.

Our response was sent on 12/21/2017. Please see the attached.December 21, 2017 [redacted], Revdex.com Serving Metro, Washington DC,and Eastern Pennsylvania1411 K Street, NW, 10th FloorWashington DC  20005-3404 RE:      ...

Complainant:             [redacted]Revdex.com File Number:       [redacted] Dear Mr. [redacted]: This letter is to acknowledge the receipt of your correspondence.  Thank you for allowing us the opportunity to further review your concerns. After reviewing the “Customer’s Statement of the Problem” the complainant appears to have issue with his Dentist, not his insurer.  The complainant also makes no mention that CareFirst is his insurer.  If indeed the complainant has a problem with his insurer, please supply a membership number as we are unable to locate any coverage for a “[redacted]”. Sincerely, Brian C. K[redacted]Brian C. K[redacted], PAHMCareFirst BlueCross BlueShieldSenior Regulatory Analyst | Executive Inquiry[redacted]