Cookworks, Inc.

This letter is in response to the complaint received by your office on 12/19/2017. Your office assigned an ID of [redacted].CareFirst Administrators (CFA) is a Third Party Administrator and we administer the benefits for the Employer Group in accordance with the conditions specified in their coverage.The Employer Group provides to its employees a self-insured, self funded plan governed by the Employee Retirement Income Security Act of 1974, as amended (“ERISA”).CFA is not acting as an insurer for any services subject to the inquiry for which this complaint is being made.CFA is a Third Party Administrator, which provides administrative and claims processing services only.The Account, not CFA, is responsible for funding any payment on behalf of the participants under the plan, including but not limited to all benefits to participants in accordance with the plan, and the account agrees to accept liability for and provide sufficient funds to satisfy all payments for covered services on behalf of the participants under the plan.The Plan’s Summary Plan Description (SPD) indicates that in order to determine appropriateness of treatment and the allowable fees, a pre-treatment authorization is recommended from the Claims Administrator for any non-emergency treatment plan which exceeds $300. An authorization with estimated benefits payable will be released after the dentist submits the treatment plan to the Claims Administrator (including the list of services to be performed) with dental codes, the itemized cost of each service, and the estimated duration of treatment.CFA received a Pre-Treatment request on 10/05/2017 for authorization of dental services totaling $1,592.00 and the Pre-Treatment estimate was issued to the Provider on 10/06/2017 via an EOB. The Pre-Treatment estimate advised the Provider that $813.00 was ineligible for dental benefits. The estimated balance of $778.92 was eligible for a payment of $623.13 and the member would be responsible for $968.87. It appears the member had services rendered on10/05/2017, which was prior to the receipt of the Pre- Treatment determination. The claim for the dental treatment rendered on 10/05/2017 was received on 11/09/2017 for a total billed amount of $1592.00. The payment of $623.13 was issued to the Provider on 11/14/2017and the member is responsible for ineligible charge of $813.00 due to exceeding the annual dental maximum of $1,000.00 and the 20% coinsurance for a total liability of $968.87. According to our records the member was advised on 10/02/2017 that $376.87 of the $1,000.00 annual maximum had be used at that time, leaving an eligible balance of $623.13. Based on our review of all documentation on file the claim processed correctly and no adjustment to the claim is required. We regret that the outcome of this review could not have been more favorable.Sincerely,Pam B[redacted]. Appeals/ Correspondence Rep.

Your inquiry of April 28, 2017 to Ms. Wanda L[redacted], Director, Executive Inquiry Department, was referred to me for review and response.Under the Health Insurance Portability and Accountability Act (HIPAA), CareFirst requires an Authorization Form, signed by the member to be included with the...

inquiry, in order to releaseinformation to someone other than the member, An Authorization Form was not included with the inquiry. Therefore, we responded directly to the member to address her complaint. I hope this information is helpful.Sincerely, Carole W[redacted] Lead Regulatory Analyst [redacted]