Coventry Health Care, Inc.

September 12, 2014Dear *** ***:
Your letter of September 4, to Coventry Health Care of Virginia, Inc("Coventry Health Care") was referred to my attention for review and response*** *** expressed concern with the $3,700.00, October 29, claim denial for The
*** ***Coventry addresses this concern below.On May 6, 2014, Coventry received a claim submission for the October 29, services, The $3,charge was denied due to an incorrect diagnosis codeOn June 19, 2014, Coventry received a corrected claim with a corrected diagnosis and procedure codeThe claim was denied due to an invalid procedure codeProviders are required to adhere to submitting claims correctly based on the Services renderedHowever, *** *** has been responsible for submitting a Superbill to Coventry on behalf of The *** ***, Coventry understands *** *** is caught in the middle of this billing issueAs a one time exception, the $3,October 29, charge will be processed, *** *** should receive an Explanation of Benefits within 7-businessIf you have any questions, please contact the Customer Service Department at ###-###-####,Teresa *E*** Manager, Complaint and Appeal Program

[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 have reached out to your company at least ten times, which clearly did not work out at allI would like someone to call me, or at least be provided with a direct contact number, rather than an email address. Again, this is the worst customer service you could provide. Your company REALLY needs to re-evaluate a few things when it comes to the customer experience. Also, I have yet to receive a bill from your company regarding the amount I owe. If I owe it, send me a bill. Don't keep trying to take it from an account, causing overdraft fees. All of this is completely your company's fault, NOT mine. As I mentioned before I transfer money to that account as I have bills due. The fees keep piling up, and I plan to recover those one way or another from your company. My next action will be to file a complaint with Consumer Affairs if this cannot be taken care of in this format
Regards,
*** ***

"Times New Roman";">Dear
*** ***,
Please
see our response to complaint #*** for *** *** that was received by us on January 4,
In
reviewing the prescription claim in question, it was found that *** ***’s
pharmacy had submitted the claim with a discontinued National Drug Code (NDC). Without having a valid NDC we are unable to
allow the claim. The denial reason code
sent back to the pharmacy specifically states that was the reason for the denial
We
did also review *** ***’s prescription benefits and found that the
medication is a tier or non-preferred medication. When using an in network provider, tier
medications apply towards the $deductible until it is met. A
Summary of Benefits and Coverage is attached for his plan which supports
that statement, as is the prescription formulary which lists the medication
as tier
It
was noted that *** ***’s still has an active policy with Coventry for
as well. All terminations must be
submitted through the Federal Health Insurance Marketplace. If he wishes to cancel his policy he may
contact the Marketplace at ###-###-####
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
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team

February 4,
Dear ***:
The Regulatory Compliance Department of Coventry Health Care of Missouri, Inc(“Coventry Health Care”) writes this letter in response to your request dated 2/3/and received at our office on that dayThis letter is in
reply to the above-referenced consumer complaint filed by *** *** *** regarding a prescription coverage
Both the member and his provider were notified of the appeal decision to approve the requested prescription the morning of 1/31/2014, prior to Coventry Health Care’s receipt of this Revdex.com complaint
Coventry Health Care hopes this explanation provides the Revdex.com with the necessary information to complete the investigation of this matterIf you have any further questions or concerns, please feel free to contact me at ###-###-####, extension ***My fax number is ###-###-####, and my e-mail address is ***
Very truly yours,

[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:
How can I have the contact informtion (Company name, address, email) from the MarketplaceI just tried again, and the estimated waiting time is minutesIf the phone doesn't work property, I need other form of contact beside phone call
Regards,
*** ***

September 12, 2014Dear *** ***:Your letter of September 9, to Coventry Health Care of Iowa, Inc(Coventry) was received in our office, and referred to my attention for review and response*** *** is on Qualified High Deductible Health Plan Open Access Health Maintenance
(QHDHP OA HMO) policy with a February 1, effective date through his spouse’s employer.In his complaint to the Revdex.com, *** *** advised that one of the billing associates with Hansen Family Clinic stated he would receive the same copay/member responsibility as other hospitals that are within the Coventry network*** *** is on a QHDHP policy and his annual family deductible is $5,*** *** does not have a copayment associated with his policyTherefore all services would be subject to his $5,annual family deductibleCoventry processed several claim submissions for *** ***The claims processed at the negotiated contract allowance with the providers*** *** would be responsible for the amount subject to his deductibleThere was no payment issued to the providers of serviceIf the providers notify Coventry that the claims should not have been submitted, the deductible amounts will be removed from *** ***’s policyAt this time, Coventry has not received any corrected claims from the provider of serviceIf I may be of any further assistance, please feel free to contact me at ###-###-#### or toll-free at ###-###-####, ext***.Sincerely,Teresa E
Manager, Complaint and Appeal Program

[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,
*** ***

August 20, Coventry Health Care responded directly to the member on May 15, 2014, regarding the abovereferenced ComplaintTo date, *** *** has not rejected our response nor has she recontacted the Revdex.com, so we request that this matter be closed.Thank you

[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:
THE REQUESTED FORM HAS BEEN EXECUTED BY CLIENT, *** ***, AND HAS BEEN ATTACHED HERETO FOR COVENTRY'S FILE.
Regards,
*** ***

Dear
*** ***,
Thank you for allowing us to address the concerns that were reported in complaint #*** for *** Terrel that was received by us on December 17, 2014, regarding an extra premium being drafted that caused overdraft fees to be applied by her bank. Our Executive Resolution Team researched your concerns, and we would like to share the results of the review with you
Our investigation determined that the issue was already being reviewed at the time we received the Revdex.com complaint. The expedited refund process had been started for the extra premium that was drafted and the overdraft fees that were subsequently applied. The refund for the premium draft of $was approved by our Accounting department and entered into the system on December 19, 2014. Once entered into the system, the turnaround time for a refund to be deposited into the bank account on file is 1-business days.
Approval was also given by the Enrollment department to reimburse for $in overdraft fees, which was the amount showing on the previous bank statements that were provided to us. The request for reimbursement of that amount was also sent to our Accounting department but requires additional levels of approval within that department and can therefore take slightly longer. We expect for the process to be completed by the end of the day on December 23, 2014, at which time the deposit of that refund will again take 1-business days.
It was noted that the amount of the overdraft fees requested in the complaint message does not match to the amount that has been approved. At present, the reimbursement is for the six overdraft fees that were reflected on the bank statement that we had received. If more fees have been assessed, we will need an updated bank statement that shows the total number and amount applied. Once received, those statements can be sent for review to determine if additional amounts can be paid.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MsTerrel’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

July 3, 2014Dear *** ***:
I am writing in response to complaint ID ***, filed by our member, *** **.We have thoroughly reviewed the complaint submitted by *** ** as well as your request for information regarding her complaint*** ** has filed this complaint
as result of the policy termination subsequent to premium payment.Our records reflect that the appropriate identifying information was missing on the check submitted as paymentAs a result, the member’s payment was held in an escrow account until the correct policy was locatedAs a courtesy we have reinstated the member’s policyHowever, premium payment is currently due for the months of May through JulyThe member may call our customer service department prioir to July 15, to make payment to avoid terminationThe phone number for our customer service unit is ***Of note, please be advised that all future premium payments should include the member’s case number on payments made by check to avoid payments going to escrowWe trust the above information is fully responsive to your requestShould you have any questions or concerns regarding this matter, please do not hesitate to contact meSincerely,Candice G
Appeal/Regulatory Complaint Coordinator Coventry Health Care

[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 However, I want them and you to understand that I had tried to resolve this multiple times by phone and email and no one ever told me I needed to sign anything or give me specific instructions as to how to take care of this I was transferred to multiple other departments and people without success and they had no clue how to help me Interesting how it was resolved only after the Revdex.com got involved
Regards,
*** *** ***

Complaint: ***
I am rejecting this response because:
I have fled an official grievance against Coventry One operating as Coventry of the Carolinas in my stateThey have failed to respond to this grievance despite their own policy that states they will respondMy original complaint was made when they failed to pay medical bills for my son despite having coverageI have evidence of questionable business practices (I have the ambulance company also to back me up since they were never paid either) and shoddy record keepingI am filing an official complaint with the state as well.I would like a response from anybody and a refund of my out pf pocket expenses which will total over thousand dollars
Regards,
*** ***

[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,
*** ***

[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:
This company has not reinstated my policy and if they did , I would only owe JulyAt this point I am requesting my payment of $be refundedI'm no longer interested in being serviced by Coventry
Regards,
*** **

Dear
*** ***,
Please see our response to complaint #*** for *** *** that was received by us on January 7,
We have determined that an error in the transmission of *** ***’s information from our billing and enrollment system to our claims and benefits system resulted in his policy not being activated correctlyThe issue was resolved by manually setting up his policy. His coverage is now active. We have also forwarded the case for further review to determine if system updates are needed to prevent the error from occurring in the future
An ID card was requested on January 7, 2015. The card will be mailed to the home address we have on file and will take about 7-business days to be received. In the meantime, *** *** may contact our Customer Service department at ###-###-#### to request his ID number and to receive instructions on where to get a temporary copy of his ID card if he wishes.
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 ***
Regards,
Chris B***
Executive Resolution Team

Dear *** ***,
Please see our response to complaint #*** for *** *** that was received by us on June 11,
During our review, it was determined that in order for *** ***’s policy to be terminated, we would need to receive a termination file from the MarketplaceA complaint would need to be filed to the Marketplace in order for the policy to be retroactively terminatedThe member’s billing cannot be adjusted until the termination file is received from the Marketplace
We contacted *** *** in order to have a conference call with the Marketplace to request a retroactive termination on April 28, In the conference call, the Marketplace representative stated there was an escalated complaint already submitted for this member on April 22, However, there was currently no identification number assigned to the complaint as of yet
The Marketplace representative advised *** *** that it may take up to days to process this termination request and that he could follow up with the Marketplace to verify the statusI have attempted to contact *** *** several times to set up a conference call with him and the Marketplace to follow up on the status of his complaint but have been unsuccessfulI would like to advise that we are unable to speak to the Marketplace on his behalf, as we are not authorized to do so*** *** can contact the Marketplace himself at ###-###-#### to follow up on the status of his complaintOnce we receive the termination file from the Marketplace, we will be able to process *** ***’s request
I apologize for any difficulties 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 *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***@***.com
Regards,
Julian C***
Executive Resolution Team

August 29, 2014Dear Sir or Madam:The Regulatory Compliance Department of Coventry Health Care of Kansas, Inc(“Coventry Health Care”) writes this letter in response to the consumer rejection complaint filed by *** *** regarding termination of her policy for non-payment,We have researched *** ***'s complaint and our initial response remains the sameWe have confirmed that the address on file with the Market Place matches what we have in our system: *** * *** *** *** ***, KS ***We cannot explain why the member did not receive our correspondenceOur system reflects this member was set up on the “Paper billing” methodThis means *** *** would have been sent a paper bill to the address indicated above, with instructions on how to make her paymentOn January 1, *** *** was mailed an initial payment letter indicating that her payment was dueWe have a record of *** *** calling our Enrollment and Billing Department on January 10, to check the status of her binder paymentThe representative explained it had not postedHowever, the initial payment posted on January 13, On March 9, she was mailed a past due letter and a cancellation letter on April 17, 2014, We did not receive any payments after the initial binder paymentDue to the other policy being terminated for January 31, 2014, there will be no coverage for *** *** from February 1st to June 30thThe older policy cannot be reinstated to cover for the lapse of coverage as it was terminated for nonpayment*** *** has a new policyThis policy is effective 07/01/for a $premium on the Silver Integrated $Copay PPO plan, *** *** has concerns regarding the delay in receiving information on her new policyUnfortunately, regardless of what may have been indicated to *** *** by the Market Place, we did not receive the file from the Market Place timelyThe system currently shows *** *** effective July 1, on a fully subsidized plan, Coventry Health Care hopes this explanation provides the Revdex.com with the necessary information to complete the investigation of this matterIf you have any further questions or concerns, please feel free to contact me at ###-###-####My fax number is ###-###-####, and my e-mail address is ***.Very truly yours,Kimberly S RN, BSN, CPCHealth Services Manager, Appeals

Dear *** ***,
Please see our response below to the additional concerns reported in complaint #*** for *** *** that were received by us on December 16,
We were unable to locate any contact through the Revdex.com or directly to Coventry requesting cancellation of the previously processed reinstatement for *** ***’s policy prior to the premiums being drafted from his bank account. However, we were able to backdate the termination of his policy to September 30, 2014. We have also requested an expedited refund for the premiums that were drafted on December 15, 2014. He can expect a refund for $to be deposited into his account within 1-business days. We have been in contact with *** *** regarding the matter.
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 you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Chris B***
Executive Resolution Team

face="Calibri">Dear
*** ***,
Please
see our response to complaint #*** for *** ***
that was received by us on January 15,
In
researching *** ***’s complaint, it was noted that the application we had
received for her policy did request a November 1, 2015, effective date. When the application was first received and
reviewed, it was determined that additional supporting documentation needed to
be provided to activate the policy. The
supporting documentation needed was proof of a qualifying event that would
allow for a midyear effective date.
Proof of termination of other insurance coverage was received in
December and the policy was activated at that time, retroactive to November 1,
2015. When the policy was activated, the
November premium was drafted.
We made a request with our Underwriting department to change the effective date of the policy to December 1, 2015. The request was granted. This allows the premium that she paid for the month of November to be credited back to her. Rather than issue a refund, we will apply the credit towards her February premium which will reduce the amount she has to pay for that month
Ms
Erb’s premium increased as of January 1, 2016, since all individual policies
are subject to be re-rated the first of every year. A notice was sent to *** *** regarding the
increase but due to the short turnaround time in between the activation of the
policy and the end of the year, she may not have received the notice in time to
read it and become aware of the change.
A letter was also sent advising her that the next premium withdrawal
would be for an increased amount in order to collect the premium for December
and the higher amount for January.
Again, with the shortened timeframes, she most likely would not have
received the adjusted premium withdrawal notice in time to deposit the required
funds into her account or cancel the scheduled withdrawal
Finally,
in order to determine if we will issue reimbursement of any overdraft fees,
Coventry requires bank statements supporting the amount of the fees. We spoke with *** *** over the phone and
requested those bank statements. They
have been received and will be forwarded to the appropriate area for
review. We will notify her directly of
the outcome of that review.
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 ***@***.comRegards,
Chris
B***
Complaints
and Appeals Consultant