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

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 months where payments submitted by the Group were improperly appliedIn both cases the payments were located and posted after the group contacted usTo mitigate the potential risk of future issues, these examples were sent to the appropriate departments for possible process improvements and technical solutionsArrangements were made with the Group to forward all future payments to one designated contact person for special handlingOnce the issues with payment posting have been corrected and the Group’s confidence has been restored we will work to reintroduce the payment submission process with them accordingly

[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: 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, [redacted] ***

[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] ***

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 IllinoisAs 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 ConnectionPlease see their website www.maryland healthconnection.gov

[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:From: [redacted] < [redacted] @ [redacted] .net>Date: Wed, Mar 15, at 11:AMSubject: Re: cid [redacted] / Care First BlueCross BlueShieldCarefirst has not resolved my complaint I have sent MrK [redacted] the documents that he requested on February 15, Please reopen this case.Thank you, [redacted] K***, 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***, PAHMCareFirst BlueCross BlueShieldSenior Regulatory Analyst|Executive InquiryMail Stop [redacted] SClinton StreetBaltimore, MD 21224www.carefirst.com Regards, [redacted]

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

[redacted] will need to contact the Exchange to discuss subsidy changesA 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 callAdditionally, an email message was sent to the [redacted] to inform her that she will have to refer back to the Exchange for assistance

Your inquiry of April 28, to MsWanda 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 inquiryTherefore, we responded directly to the member to address her complaintI hope this information is helpful.Sincerely, Carole W [redacted] Lead Regulatory Analyst [redacted]

This letter is in response to the complaint received by your office on 12/19/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 $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/for authorization of dental services totaling $1,and the Pre-Treatment estimate was issued to the Provider on 10/06/via an EOBThe Pre-Treatment estimate advised the Provider that $was ineligible for dental benefitsThe estimated balance of $was eligible for a payment of $and the member would be responsible for $It appears the member had services rendered on10/05/2017, which was prior to the receipt of the Pre- Treatment determinationThe claim for the dental treatment rendered on 10/05/was received on 11/09/for a total billed amount of $The payment of $was issued to the Provider on 11/14/2017and the member is responsible for ineligible charge of $due to exceeding the annual dental maximum of $1,and the 20% coinsurance for a total liability of $According to our records the member was advised on 10/02/that $of the $1,annual maximum had be used at that time, leaving an eligible balance of $Based on our review of all documentation on file the claim processed correctly and no adjustment to the claim is requiredWe regret that the outcome of this review could not have been more favorable.Sincerely,Pam B***Appeals/ Correspondence Rep

The member had dual enrollment with CareFirst for on exchange and group coverage from 8/1/to through 8/1/CareFirst did not speak with the member until 9/11/to discuss refund of payment made for the month of August 2017; the members on exchange coverage was already terminatedThis case is currently with DC Healthlink to confirm the members call history on their end

[redacted] submitted a ‘Notice About Medical Assistance' to CareFirst as proof of other insurance effective 4/1/The member's policy with CareFirst terminated for non-payment of March's premium; the policy has a 3/31/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 $1,($for the month of March + x $for the months of April-July) since the effective date to remove the dependents is after the 3/31/termination date.If payment is made and the policy is reinstated, the dependents can be removed effective 3/31/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,on Friday, 7/1/[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