Coventry Health Care, Inc.

October 6, 2014Dear Sirs:This letter is in response to the aforementioned Case Number [redacted] regarding [redacted]’s PCP selections and assignment. [redacted] also requested to be reimbursed if a PCP is not found.Please be advised that after review of your grievance, [redacted]...

is effective with the CATASTROPHIC $20 HMO plan as of April 4, 2014. [redacted]’s plan does require PCP assignment. This is important to the coordination of care, and members are encouraged to contact their PCP when medical care is needed.[redacted] can select a PCP from one of the following specialties: Family Practice, Internal Medicine, General Practice, OB/GYN, or Pediatrics. [redacted] may choose one PCP for the entire family, or each Dependent may select a different PCP. To locate the most current Directory of Health Care Providers, please visit our website at [redacted] . Our online Provider directory is updated at least monthly. Please find (enclosed) a list of General Practice and Internal Medicine PCP’s within 20miles of [redacted] zip code. If [redacted] wishes to change her PCP, she must contact our Customer Service Department at ([redacted]. [redacted] may also visit our website at [redacted] to make this change,In regards to a refund for coverage, [redacted] must request to have her plan terminated through the Marketplace. However, [redacted] currently has access to many benefits of her coverage such as PCP visits, Urgent Care, Pharmacy and Emergency Room care.[redacted] has no refund due at this time. Please see the termination section of the policy below:Termination by Subscriber:The Subscriber may terminate Coverage for himself/herself and any enrolled Dependents under the Contract for any reason by providing fourteen (14) days advance written notice to the Health Insurance Marketplace. For notices received on the 1st through 15th day of the month, termination will take effect on the first day of the month in which the notice was received. For notices received on the 16th through 31st day of the month, termination will take effect on the first day of the month following the month in which the notice was received, unless the Health Plan agrees to an earlier termination. The notice of termination should be sent to the Health Insurance Marketplace through which You enrolled.If you have any questions, please contact Customer Service at ###-###-####, Monday through Friday from 8:30 am until 5:30 pm or you may reach me directly at ###-###-####. If you are hearing impaired please call 7-1-1 Telecommunications Relay Service.Sincerely,Yanique MAppeals Coordinator Grievance & Appeals Department

CID:
10601119
Date Filed:
3/26/2015 12:00 AM
Nature of Complaint:
Customer Service Issues - No Detail Provided
select
Problem:
Company has been asked repeatedly to fix this issue including in Revdex.com.org Complaint #[redacted]. No action from Company to resolve. Applications from Marketplace processed incorrectly and double billed. After resolved issue with Marketplace (1/15) will not accept payment. Member Number: [redacted] Initial application of 3/14 accepted and paid through 8/14. Move to new county reported for move date 6/30/14 was not made effective until 9/1/14. Inproper billing was reported to Coventry. Multiple calls placed with same issue. No response and threatening calls demanding payment. Call to Marketplace and assigned case worker. Case worker finished adjustments to second half of 2014 in 1/15. Payments are not accepted by Coventry for the second premium after 10/31/14 regardless of error being on Coventry's part. Multiple phone calls to billing were placed and at least half resulted in operator hang-up. Requested Manager/Supervisor in multiple instances and was given to another non-managerial operator. Payment has been tried to be paid since 10/14 in multiple calls. Operators repeatedly state unable to take or process payment because of errors on the account and/or they do not see the account after the move to the new county. No resolution suggested. No cooperation or 3rd party call to Marketplace. Marketplace notified of potential they may have closed an application which should be open and was thoroughly researched and discredited as a potential issue. Multiple operators rude and threatening during calls with attempt to pay correct premium. Same behavior has been experienced when called by billing department demanding incorrect payment of hundreds of dollars higher than premium. Though the Marketplace states Coventry will cover for Nov 14-Jan 15 no one in Coventry able to accept payment and multiple operators state will not be covered due to lack of payment. 8 months straight attempting to assist with or talk about the need to have account updated to the correct billing and multiple involvements with Marketplace have still not resolved anything with Coventry no matter how many times they are called. Complete disregard for Marketplace case worker and resolution reported to Marketplace not instated. Company please address properly with new information submission concerning letter from Company acknowledging there is an issue which they did not resolve within the stated time period needed to pay bill. Company continues to state payment is not possible while Healthcare Marketplace states they are required to take payment for the time in question due to the need for the Healthcare Marketplace intervention on account billing issue. Reference issue #[redacted]
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Desired Settlement / Outcome
Desired Settlement:
select
Desired Outcome:
Accept payment as per terms stated by the Marketplace and coverage for November 2014, December 2014, and January 2015 with retroactive claims processing from July 2014 through January 2015 without further issue. Review of 80/20 spending. Update to the deductible to have full year correctly billed as deductible was met in prior (March to June)portion of the year. Same for the other account held by the household under second policy. All resolutions effective as soon as possible with payment to phy
CID:
10601119
Date Filed:
3/26/2015 12:00 AM

[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

July 28, 2014Dear [redacted]The Member is participating in the Coventry Health and Life Insurance Company (“CHL”) HealthAmerica One individual off exchange HMO health benefit plan.
The Member’s complaint concerns overdraft fees applied due to premium payments drafted from the...

Member’s bank account for 11 months in error. The member is requesting a refund of her overdraft fees in the amount of $961.Below is a timeline of events leading up to the resolution of the member’s complaint.January 13, 2013 – The Member contacted Billing & Enrollment department in regards to his copay. He was transferred to the Claims & Benefits department.May 5, 2014 – The Member contacted Billing & Enrollment department to terminate his coverage because he has had another policy for a year. The member was advised to send in proof of other coverage to seek approval for a retro-termination.May 21, 2014 –The Member contacted Billing & Enrollment department to check the status of his policy. He was advised that his policy was terminated effective May 31, 2014. The member states that he is seeking a termination date of April 30, 2013.June 9, 2014 –The Member contacted Billing & Enrollment department to inquire on the status of his policy. The call was lost.June 9, 2014 –The Member contacted Billing & Enrollment to check the status of his refund. There is no refund due because the member’s payment returned.June 13, 2014 –The Member contacted Billing & Enrollment department to request a change of address.June 25, 2014 –The Member contacted Billing & Enrollment department to request a refund for the past year of coverage. The member was advised that the refund was not approved.July 18, 2014 – The Member contacted Billing & Enrollment department to check the status of his termination and refund.July 23, 2014 – The Member contacted Billing & Enrollment department to check the status of his refund. The member was advised that at this time no refund was due.On July 24, 2014 – The Member spoke to a CHL representative. The representative read the notes left by the resolutions team and went over the billing with the member. The representative who took the call stated the member understood the breakdown of the billing and now understands why there is no refund due.ROOT CAUSE:The member had coverage through another carrier effective May 1, 2013, but did not terminate his plan with Coventry.RESOLUTION:A request has been sent to the home office for a retro-termination.If you have any questions or concerns regarding this matter I can be reached at ###-###-####.Sincerely,Emily M
Appeals Coordinator

[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:
 Because they still have not refunded me my money ... Any of it and they told me multiple time that they were going to refund the full amount then said they wouldn't refund the full amount... Also I called and cancelled late February not March 4th as they say... They are liars and continue to lie..
Regards,
[redacted]

Dear...

[redacted],
Thank you for allowing us to address the concerns reported in complaint #[redacted] for [redacted] that was received by us on December 5, 2014, regarding an adjustment performed on the claim for services provided to him on April 26, 2013.  Our Executive Resolution Team researched your concerns, and we would like to share the results of the review with you.
Our research determined that we had initially applied $75.20 as [redacted]’s responsibility due to the deductible on his plan.   The provider of services later discovered that the allowed amount on the claim did not match to their expected allowed amount and requested that the error be corrected.  The correct allowed amount was $199.84.  This corrected allowed amount was also applied to [redacted]’s deductible, so he became responsible for an additional $124.64.
Due to the length of time that had passed between the initial processing of the claim and the correction, a business decision was made to waive the additional deductible applied and instead have the plan pay the $124.64 to the provider.  The initial deductible amount of $75.20 was still applied, but as long as [redacted] has paid that amount, he will not owe any additional money to the provider for this claim. 
I have forwarded the information submitted in the complaint to our Legal department to ensure our reprocessing of the claim was in accordance with Georgia state law.  I will send out additional information once that department has reached a decision. 
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].
Regards,
Chris B[redacted]
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 [redacted], and find that this resolution is satisfactory to me.  
I will call to follow up and make sure but greatly appreciate the efforts put forth recently to help us clear up this mess.
Regards,
[redacted]

Dear [redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on May 01, 2015.
Based on our review, [redacted] can disregard the past due letter he received. The letter was sent on April 11, 2015, and the policy wasn’t terminated until April 23, 2015. [redacted] is currently showing a $0.00 amount due for his policy.
[redacted] also requested a Certificate of Creditable Coverage (COCC). Unfortunately, these are no longer provided. However, [redacted] may keep this response for his records. I apologize for any 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] or ###-###-####.
Regards,
Julian C[redacted]
Executive Resolution Team

February 6, 2014
Dear **. [redacted]:
The Health Plan received your request to our initial response on February 5, 2014. In response to your rejection:
**. [redacted] would have to call the exchange for this or see if they were willing to move his effective date due to the circumstances. As this is an on exchange plan and the binder payment is a requirement to hold the policy, we could not make an exception to refund. Either way the Health Plan is limited to what is fed to us by the exchange. Making a payment prior to issuance is part of the requirements for polices offered on the exchange. There is no consideration for partial month; that is not an option the Health Plan can offer, according to Federal Guidelines.
In addition, on February 5, 2014, a replacement request was made to have **. [redacted]’s cards mailed. **. [redacted] can go to our website, www.chcflorida.coventryhealthcare.com to download a temporary member ID card to fill prescriptions and schedule appointments. **. [redacted] can contact our Customer Service Department to verify his policy and coverage.
If you have any additional questions, please contact me toll free at ###-###-####, extension [redacted] or directly at ###-###-####, Monday through Friday from 8:00 am until 5:00 pm. If you are hearing impaired please call TTY 7-1-1 Relay.
Sincerely,

[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:
Regards,
[redacted]
It is apparent from there response is valid.  How do I make calls get hung up on, get the responses that I did, and then have a company ssimply respond by we have no record, so it didnt happen.  Obviouslu, that is how they keep getting away w their bait abd switch service (promising customer servive, than making it impossible to obtain).  Then when a customer reaches out for third party intervention to encouragevthe company to honor their promoted service, this company hides behind "no record, didnt happen".  This is why businesses behave in this manner, because there allowed to withiut reprucussion.  Shame on coventry and shame on our system.

July 14, 2014Dear Sir or Madam:The Regulatory Compliance Department of Coventry Health Care of Missouri, Inc. (“Coventry Health Care”) writes this letter in response to the consumer complaint filed by [redacted] regarding payment issues for her policy.As [redacted] was concerned...

about payment drafting, a representative contacted her on July 2 and verified that the bank account information is correct in our system. [redacted] has a policy for which the member’s portion is $130.84 and APTC pays $270.00 or $400.84 for the total monthly premium. She paid $130.84 on June 30 which has her paid through July 31, 2014. [redacted]’s next premium payment of $130.84 is due on July 31 for the month of August.Coventry Health Care hopes this explanation provides the Revdex.com with the necessary information to complete the investigation of this matter. If you have any further questions or concerns, please feel free to contact me at ###-###-####, extension 1917. My fax number is ###-###-####, and my e-mail address is [redacted]Very truly yours,Neil M[redacted], B.A. Regulatory Compliance Analyst Coventry Health Care

Coventry needs to find out which agent or represented spoke to me declining my original request to reinstate after we found out we were terminated. The rep told me she could not find any such phone call made on the 29th to keep my policy active, not to terminate. My wife and I called back several times to talk to supervisors about reinstatement, only to be placed on hold for 30 minutes both times and than to be disconnected without a call back from anyone. It was not until I filed a complaint with insurance commissioner of GA that we finally mysteriously found that phone call that was made on the 29th of October and was reinstated.       
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID 10315083, and find that this resolution is satisfactory to me. 
Regards,
[redacted]

face="Calibri">[redacted]
Please see our response to complaint #[redacted] for Kelly Layburn that was received by us on May 11, 2015.
During our review, we found that the member’s policy was created on December 04, 2014, with an effective date of January 01, 2015. [redacted] policy was terminated as of March 31, 2015, due to non-payment. The member has a current amount due of $2,835.75 for April, May and June premiums. [redacted] needs to contact the Marketplace at ###-###-#### to cancel her policy.  
According to [redacted]’s benefits, the in-network deductible is $5,000 per person and $10,000 per family. The out-of-network deductible is $12,500 per person and $25,000 per family. The claims in question were never denied, but were processed at the out-of-network benefit level because the member went to an out-of-network provider. However, after further review of claims in question and the member’s benefits for emergency room services, we determined they were processed incorrectly.
According to [redacted]’s emergency room benefits, the claim should always be paid at the in-network rate regardless if the services are provided by an out-of-network provider.  These rates are as follows: $500.00 co-pay per visit (both in-network and out-of-network). The three claims in question will be reprocessed and paid at the in-network rates. Once the claims are reprocessed, the member’s responsibility should be $500.00. Unfortunately, we are unable to provide the member with the refund she is requesting for January, February and March premiums, as the member did have available coverage during these months.
I apologize for the difficulties and frustration 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] or ###-###-####.
Regards,
Julian C[redacted]
Executive Resolution Team

September 16, 2014
Dear Sirs:This letter is in response to the aforementioned Case Number [redacted] regaining **. [redacted] termination of coverage and locating a Pain Management Provider that prescribes “[redacted]”Please be advised that after review of your grievance, **. [redacted] was contacted and informed about the criteria regarding [redacted] prescriptions. **. [redacted] was advised she will need a referral from her (PCP); who will request authorization from Coventry Health Care, Inc. **. [redacted] expressed that she is not satisfied with Coventry’s process surrounding [redacted] prescriptions. **. [redacted] stated she anticipates termination and then ended the callPlease find (enclosed) Analgesics, Narcotics and Narcotic Combinations and Termination Criteria. Additionally, below is part of the criteria for; Analgesics, Narcotics and Narcotic Combinations and Termination:A documented diagnosis of moderate to severe chronic painANDFormal, pain evaluation has been documentedANDOther pain management regimens have been inadequateTermination by Subscriber:If **. [redacted], still needs to terminate her policy; she must return to the Marketplace in order to terminate her coverage. According the Certificate of Coverage (enclosed) Section 3 Termination of Coverage; A, Termination by Subscriber:The Subscriber may terminate Coverage for himself/herself and any enrolled Dependents under the Contract for any reason by providing fourteen (14) days advance written notice to the Health Insurance Marketplace. For notices received on the 1st through 15th day of the month, termination will take effect on the first day of the month in which the notice was received. For notices received on the 16th through 31st day of the month, termination will take effect on the first day of the month foll owing the month in which the notice was received, unless the Health Plan agrees to an earlier termination. The notice of termination should be sent to the Health Insurance Marketplace through which You enrolled.If you have any questions, please contact Customer Service at ###-###-####, Monday through Friday from 8:30 am until 5:30 pm, or you may roach me directly at ###-###-####. If you are hearing impaired please call 7-1-1 Telecommunications Relay Service.Sincerely,

October 10, 2014Dear [redacted]:
This letter is in response to the aforementioned Case Number [redacted] regarding [redacted]’s complaint.After review of this complaint, the Health Plan has confirmed that [redacted] is not currently enrolled with the Health Plan’s PREM...

25/$7500 PPO effective June 1, 2011 to May 31, 2014. [redacted] is currently enrolled with the Health Plan’s BRONZE $10 HMO PD PLAN effective June 1, 2014.On September 11, 2013, the Health Plan sent [redacted] a letter (enclosed) advising that the Affordable Care Act (ACA) would begin in January 1, 2014. With the launch of federal and state exchanges, also known as marketplace, the Health Plan offered [redacted] the option to keep the benefits he has today. This would allow [redacted] to start a new policy, with the same benefits he currently had, which would have become effective December 1, 2013. This new policy would have replaced [redacted]’s current plan with the new Health Plan, and would remain in force until December 31, 2014. Enclosed with this letter was a “New Policy Confirmation Form” that he could sign and return. As indicated in the letter, if [redacted] had any questions about this new policy, he could have called us at ###-###-####. Our team of experts is available from 8 a.m. to 8 p.m., Eastern Time.In addition, on March 28, 2014 the Health Plan sent [redacted] a Migration letter (enclosed) advising that his plan design(s) would not change until his policy period ended on May 31, 2014. At that time he would need to have a new 2014 plan in place so he did not have a gap in health coverage. When his policy ended, he would have three (3) options. However, when the Health Plan did not receive back either form, [redacted] was auto-enrolled onto a new ACA plan, option 1. Option 1 states:OPTION 1 - Allow us to automatically move you to a plan that based on your current coverage may meet your needs, and also meets all of the ACA requirements. If we do not hear from you or you do not take any action, we will enroll you into our Bronze $10 Copay HMO PD, effective June 1, 2014.
At this time no plan changes can be made without a qualifying event. The premium for this plan is $800.81 per month. Visit http://www.coventryhealthcare.com/fl72633 to view the Summary of Benefits and Coverage for this plan. You can call ###-###-#### to obtain a Certificate of Coverage and/or a Schedule of Benefits.
Further, on July 8, 2014, the Health Plan received a complaint from the Department of Financial Services regarding the same issue from [redacted]. On July 10, 2014, the Health Plan addressed [redacted]’s complaint with the Department of Financial Services. We have not received any additional phone calls or request for additional information to date.Coventry Health Care hopes this explanation provides the necessary information to complete the investigation of this matter. If you have any additional questions, please contact me directly at ###-###-####, Monday through Friday from 8:00 am until 5:00 pm.Sincerely,
Siana L
Senior Complaint and Appeal Analyst Grievance and Appeals Department

[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: 
The response is acceptable with one amendment. Because Coventry failed to respond in a timely manner, a claim from [redacted] Emergency Services in January 2014 for $548.00 was sent to the collections agency [redacted]. I am now responsible to pay the full amount for these services out of pocket because it is no longer in the hands of the provider...not to mention, failure to do so is damaging my credit. I would like a check from Coventry for the amount they would initially be responsible for, so that I may apply it towards this out of pocket expense. 
Thank you for your response. 
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:
THANK YOU SO VERY MUCH 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]

Dear Ms. [redacted],
Please see our response below to the additional concerns reported in complaint #[redacted] for [redacted] that were received by us on January 20, 2015.
We have attached a copy of the automatic renewal letter that was sent to Mr. [redacted].  The letter was sent and was never returned to Coventry as undeliverable.  We are unable to offer further explanation on why he never received the letter so that he could review the offer. 
It was confirmed that the termination request for his policy and proof of other coverage that we received on January 9, 2015, did not provide an effective date from his other insurance carrier.  The ID card also did not give us the effective date.  Additional information was received by Coventry on January 21, 2015, which allowed us to terminate his coverage back to December 31, 2014.  A refund was issued for the premium payment of $186.08 that we had collected for his coverage for January 2015.  The refund process was completed on Coventry’s side on January 27, 2015, but it may take 1-5 business days from then for his bank to credit his account. 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].
Sincerely,
Chris B[redacted]
Executive Resolution Team

Problem:
ACH Debit for Initial Health Care policy premium was on 12/3/2013. Did not hear anything from Coventry One (no e-mail, regular mail, phone call) until 1/23/2014. Thinking I did not have a policy, I bought a policy with one of their competitors. Eventually given the phone number for the Manager of Claims and Appeals. Called 7 times between 3/17 and 3/24 during working hours - sent to voice mail every time. Left detailed messages. No call-backs. No acknowledgment. I have sent a total of 3 letters respectfully requesting a refund with no resolution. This policy was never in force and the Health Marketplace has it terminated and marked as such.
Desired Settlement / Outcome
Desired Settlement:
select
Desired Outcome:
I would like a refund of my $909.26 premium payment since the policy was never in force.

Dear [redacted]...

[redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on May 06, 2015.
During our review, we found that the member’s initial policy was created on June 24, 2014, with an effective date of July 01, 2014, and a premium of $232.40 with an Advance Premium Tax Credit (APTC) of $134.00. Starting January 01, 2015, the member was enrolled in a new policy with a premium amount of $262.10 with an APTC of $134.00. Starting on March 01, 2015, the member was enrolled in a new policy with a premium amount of $396.10 with an APTC of $0.00. Starting on April 01, 2015, the member was enrolled in a new policy with a premium amount of $148.10 with an APTC of $248.00.
The member was enrolled in Electronic Funds Transfer (EFT) for her recurring premium payments. When the member was billed for March, the amount drafted was for $262.10, which was incorrect. Since the member did not have an APTC for that month, the member had a 30 day grace period to avoid termination. We reinstated the policy without any lapse in coverage since the member was billed incorrectly for the March premium. The member is currently paid through February 28, 2015. The member owes a total amount of $692.30 for March, April and May premiums. The member can contact Coventry Member Services at ###-###-#### to make a payment.
I apologize for the difficulties and frustration [redacted] encountered with customer service. Feedback has been provided to the Customer Service department for improvement opportunities.
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] or ###-###-####.
Regards,
Julian C[redacted]
Executive Resolution Team