Coventry Health Care

"Times New Roman";">Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on January 21, Upon receiving the complaint, we found that [redacted] is on a Medicare Part D plan We reached out to our Medicare Grievance team and found that they were already aware of the situation Contracted pharmacies cannot refuse to fill a medication because they feel they are underpaid This issue has been escalated to our Network Team to find a solution so that this does not happen in the future Until a solution can be found, should [redacted] be refused a medication, we advise that he ask the pharmacy to contact our Customer Service department at the number located on his ID card [redacted] had indicated that he paid the pharmacy out of his pocket for the medication We encourage him to submit a claim for reimbursement of the amount he paid A prescription claim form is attached that can be used to file for reimbursement Please note that a receipt from the pharmacy is required to be sent with the claim formThe receipt must include specific information including the patients name, the prescription number, the medicine’s national drug code number, the date of the fill, the metric quantity, the total charge, the number of day’s supply for the prescription, the pharmacy’s name, address, and [redacted] Number, and the prescribing physician’s National Provider Identification number In reviewing the messages [redacted] had sent through our online member portal, it was noted that attempts had been made to contact [redacted] by phone but were not successful A Grievance response letter was sent on January 15, 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] @***.com Regards, Chris B [redacted] Complaints and Appeals Consultant Executive Resolution Team

November 24, 2014Dear [redacted] : Your letter of November 14, to Coventry Health Care of Virginia, Inc(“Coventry Health Care”) was referred to my attention for review and response [redacted] expressed concern that her policy terminated due to being reported as deceased on her enrollment fileCoventry addresses this concern below[redacted] was enrolled in Electronic Funds Transfer (EFT) for her monthly premium payment of $On May 5, 2014, the last monthly premium payment via EFT was processed to [redacted] ’s account form May coverageOn May 9, 2014, Coventry issued a letter to [redacted] advising her policy would terminate oil May 31, because the coverage was not going to be available for her geographical area effective June 1, The letter also advised she was eligible to enroll in a different plan that would be offered in her area during her renewal period, On October 21, 2014, [redacted] contacted the Billing and Enrollment Department to inquire about her policy termination [redacted] 's policy did not terminate due to a reporting of her death, The Customer Service Representative (CSR) misinformed [redacted] about the termination remarks on her accountThe Health Plan Home Office utilizes multiple termination remarks codes to signify the discontinuation of a policyThe termination remarks on [redacted] ’s account indicated that she lived outside of the coverage area, [redacted] ’s policy is not eligible for reinstatement because the policy that she had is discontinued for her area [redacted] is eligible to apply for new coverageCoventry apologizes for the incorrect termination information [redacted] received from the CSREducation has been provided to CSR to prevent this error from reoccurring, If you have any questions, please contact the Customer Service Department at ###-###-####Sincerely, Shawn M Complaint and Appeal Analyst

October 17, 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 his questions on what types of services go to his deductibleThis member is currently enrolled in a fully insured, non-grandfathered, PPO, individual health insurance plan with Coventry Health Care as of January 1, through the on-exchange MarketplaceThe member's instant complaint is regarding a surgery that was scheduled for September and the current deductible he has met to dateThe member believes his deductible should already have been met due to doctor visits, ER visits, laboratory services, and diagnostic services to date for the calendar yearAs of September 23, the member has met $62,of his $1,annual, in-network deductible; however, he has already met his out of pocket maximumIn Coventry Health Care’s response to the Missouri Department of Insurance's inquiry regarding this same member, we attached an Explanations of Benefits and spreadsheet explaining which services applied to the member deductibleWe arc not including this information herewith due to HIPAA concernsThis member’s deductible and out of pocket maximum reset each calendar year, and as such, since the member has met his out of pocket maximum for 2014, he will not experience a cost share on any service through December 31, 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 [redacted] , extension ***My fax number is ###-###-####, and my e-mail address is [redacted] Very truly yours, Neil M Regulatory Compliance Analyst

face="Calibri">Dear [redacted] , Please see our response below to address [redacted] ’s concerns reported in complaint # [redacted] that was received by us on November 19, 2014, regarding overpayment of premiums Our records show that no overpayments have occurred In reviewing the bank statements sent by [redacted] to the Enrollment department and the premium payment history for her policy, we determined that the debit for $appearing on her bank statement on September 24, was actually collected on August 29, 2014, and was posted to her account with us on September 2, 2014, as payment for coverage for the month of September The debit for the same amount that appears on her statement on October 1, was applied toward her premium for coverage for the month of October In reviewing [redacted] ’s complete payment history, we show that we have collected seven separate premium payments, each for $226.96, for coverage for the months of May through November As the appropriate amounts have been collected, no refund is due at this time 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 or she have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @aetna.com Regards, Chris B [redacted] Executive Resolution Team

-------- Forwarded message ----------From: # Revdex.com of Metro Washington DC Date: Mon, Sep 15, at 4:PMSubject: Fwd: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint # [redacted] .To: [redacted] < [redacted] > ---------- Forwarded message ---------- From: [redacted] *** < [redacted] > Date: Mon, Sep 15, at 11:AM Subject: Re: You have a new message from the Revdex.com of Metro Washington DC & Eastern Pennsylvania in regards to your complaint # [redacted] To: [email protected], I recently filed a complaint with a business, Coventry Health Care, IncThe business just responded to my complaint, and has resolved my issueTherefore, I no longer wish to proceed with the complaintThe number of the complaint is ID [redacted] I greatly appreciate your help in this matter Thank you, [redacted] ###-###-####

[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: [redacted] I am rejecting this response because: I sent them info and proof that a refund has not been received is there anything legally I can do against them instead of bouncing emails bank and forth in which they just keep lying and stealing my money? Regards, [redacted] ***

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on December 30, Our investigation into the complaint determined that [redacted] had contacted eHealthInsurance to begin the process of applying for the policy but that they had submitted the request for coverage through the Marketplace For and he has been covered under plans that are only offered for members who apply through the Marketplace We are also showing that he is receiving an Advanced Premium Tax Credit (APTC) to help pay a portion of the premium that he would otherwise need to pay in full The APTC is only available to policies applied for through the Marketplace The previous representatives were correct in advising that the requests for termination must be made with the Marketplace in these situations This is the standard process that all insurance carriers selling plans through the Marketplace must follow When [redacted] filled out the termination request for his policy it was sent to eHealthInsurance, who then forwarded it to Coventry Unfortunately, we were not able to process the request If he is unable to terminate the policy through the Marketplace himself, he may wish to contact eHealthInsurance once again and advise them to submit the request for him through the Marketplace [redacted] will continue to receive notices advising him that we have not received his premium payment for now These notices will not affect his credit nor will we send him to collections for those amounts If he does not pay the premiums, his policy will eventually terminate for nonpayment, but this will not occur until March 31, His policy end date would then be January 31, 2015, even if he never pays the premium for the month of January This is in accordance with the grace period policy that Coventry must follow for members receiving the APTC 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] Regards, Chris B [redacted] Executive Resolution Team

November 10, 2014Thank you for your inquiry received on November 04, 2014, regarding complaint # [redacted] for [redacted] and his request for termination of his policyOur Executive Resolution Team researched your concerns and I would like to share the results of the review with you.We reached out to our Enrollment department for assistance during our investigationNo letter was found requesting termination of the policyRegardless, the member obtained his policy through the Marketplace so all termination requests must be made with the MarketplaceThe member made three payments that covered May, June, and July The policy has now been terminated effective August 31, 2014, due to nonpayment of the premiumThe member was allowed a day grace period and when a payment was not received by the end of the grace period our Enrollment department processed the termination on October 31, Even though no payment was made for the month of August, the policy remained active for the first month of the grace period in accordance with the policy setup for the Marketplace members with subsidized premiums.The member did request to terminate through the Marketplace in November and a termination file was sent on November 03, This file had an effective date of termination of November 30, However, this file did not process as the policy was already being terminated for nonpayment.The phone number ###-###-#### is a valid number for reaching Coventry Enrollment representativesWe apologize that the member was not able to reach someoneWe have shared the member's experience with the management team in our 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 concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] @aetna.com.Sincerely,Christopher B Complaint and Appeals Consultant Executive Resolution Team

September 29, 2014Dear [redacted] :Thank you for giving Coventry Health Care of Georgia, Incthe opportunity to review your Revdex.com complaint regarding the non-coverage of [redacted] contraceptiveWe appreciate your feedback in regards to our Customer Service process[redacted] ( [redacted] ***) is not a no cost sharing agent under your pharmacy benefit plan, unless the prior authorization requirements are metPlease have your physician contact the Pharmacy Department at ###-###-#### to initiate the prior authorization processThe prior authorization requirements include physical or mental incapacity to take oral contraceptives.If you have any questions, please contact Customer Service at ###-###-####.Sincerely,Appeals Department

October 17, Dear [redacted] ***: This letter is in response to your written inquiry dated September 24, In that correspondence you asked about the following: You expressed concern about the cost of your medications using your First Health Part D Essentials (PDP) Plan.Based upon a review of your benefit plan, you contacted the Revdex.com regarding your concern over the cost of medications using your First Health Part D Essentials (PDP) PlanYou shared that you have experienced difficulty affording your medications and would like assistance from your planWe are deeply sorry to learn of your experience and frustrationWe would like to provide an overview of the First Health Part D Essentials (PDP) Plan.As a reminder, the First Health Part D Essentials plan is a tier planAfter you meet your deductible of $310, you will enter the Initial Coverage stageDuring your Initial Coverage stage what you pay for medication will depend on what tier the medication is on and where you fill your medicationThe tier of each medication can be found in your formularyAdditionally, by using our preferred pharmacies, you can lower your cost share for covered prescriptionsOur preferred pharmacies in your area include: [redacted] Pharmacy, [redacted] Pharmacy, and [redacted] PharmacyIn addition to these major retailers, your preferred pharmacy network also includes some local pharmaciesYou may refer to your pharmacy directory for local pharmacies in your area that are included in our preferred pharmacy networkFor questions about a particular drug or pharmacy, please contact the number listed at the end of this letterYou remain in this stage until the total cost of your covered drugs (the amount you pay combined with the amount we pay) reaches $2,After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugsYou will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.After your yearly out-of-pocket drug costs reach $4,550, you would enter the last stage of coverage known as the Catastrophic stageDuring this stage, the plan will pay most of the cost for your covered drugs for the remainder of the calendar yearYour share of the cost for a covered drug will either be a coinsurance (percentage of the cost) or a copayment, whichever is the larger amountYou will pay either a coinsurance of 5% of the cost of the drug or either a copayment of $for a generic drug (or drug that is treated like a generic) or a copayment of $for all other drugsIn your inquiry, you expressed a concern about your prescription copaysTo address this concern, we would like to share the following information with you regarding the plan design and cost share associated with your First Health Part D Essentials (PDP) PlanAfter the $deductible has been met, the cost share associated for a drug filled at an in-network preferred pharmacy during the initial coverage stage is as follows: day supply day supply Tier drug $????? $????? Tier drug 15% coinsurance 15% coinsurance Tier drug 44% coinsurance 44% coinsurance The design of our plan for takes many factors into consideration including feedback received directly from our membersCopays are an effective way to help members budget for their expected drug costsThis change was made in an effort to improve our plan design for members and lower their overall out of pocket costsIf the cost of your medication is less than the co-pay assigned to your drug, you will pay the negotiated rate for the drugWe appreciate your feedback as it will help us design plans that meet our members’ needs in the futureYou commented that your plan is not providing coverage for any of your medicationsOur records indicate that your enrollment in the First Health Part D Essentials (PDP) Plan ended on April 30, This termination of coverage was due to non-payment of your plan's monthly premiumThe premium associated with your First Health Part D Essentials (PDP) Plan is $per monthIf you do not pay the plan premiums for two (2) or more calendar months from the date on which the monthly plan premium was due, we must end your membership in the planThis does not apply to full dual members and members receiving “Extra Help”We must notify you in writing that you have two (2) calendar months to pay the plan premium before we end your membershipLow Income Subsidy (LIS) and dual eligible members will not be dis-enrolled for failure to pay premium [redacted] ***, you shared that you are disabled and have a low monthly incomePeople with limited incomes may qualify for extra help to pay for their prescription drug costsIf you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insuranceAdditionally, those who qualify won’t have a coverage gap or a late enrollment penaltyMany people qualify for these savings and don’t even know itFor more information about this extra help, contact your local Social Security office, or call Social Security at ###-###-####TTY users should call I-800-325-0.778, You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelpYou also shared that you do not have Prescription Drug CoverageWe encourage members to make well-informed healthcare decisionsIf you would like to explore other plan options for 2015, we encourage you to contact a SHIP counselor at ###-###-####, Monday through Friday 8:00am - 5:00pmYou may make changes to your Medicare coverage during the Annual Enrollment Period (AEP) starting October through December to be effective January [redacted] ***, you expressed in your inquiry to the Revdex.com that your desired outcome is for First Health Part D Essentials (PDP) to provide you with coverage for your medicationsWe would like to offer our sincerest apologies to you, but unfortunately as indicated above, you are no longer a member of the First Health Part D Essentials (PDP) Plan as of April 30, Because you are no longer a member of a First Health Part D plan, we are unable to provide coverage for your medicationsWe encourage you to contact Social Security and/or a SHIP counselor to learn about any financial assistance programs that you may qualify forWe appreciate you contacting us, and trust the additional information that we have provided satisfactorily addresses your inquiryYour inquiry provides us with valuable insight as we continuously seek opportunities to improve our member communication materialsThank you for allowing us to serve your prescription drug needsShould you have any further questions, please contact Customer Service at ###-###-####, hours a day, seven days a week your local timeTTY/TDD users please call | Telecommunications Relay ServicesSincerely, Kristy H Medicare Appeal & Grievance Coordinator

Dear [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on December 30, We reached out to our Underwriting department to determine if an exception could be granted to allow [redacted] to be enrolled on his policy with the effective date of January 1, The exception was approved We have confirmed that the enrollment process was completed on January 13, 2015, and the policy now shows active as of January 1, ID cards will be sent to the address we have on file for [redacted] , but they will generally take 7-business days to arrive He may contact our Customer Service department at [redacted] to request his ID number and to receive instructions on where to get a temporary copy of his ID card if he wishes We apologize for the extra time needed to resolve [redacted] ’s complaint We appreciate you documenting the extension of the due date that we requested on January 9, This extension was needed while the final decision was made in regards to the complaint 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] Sincerely, Christopher B [redacted] Executive Resolution Team

September 16, 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 CriteriaAdditionally, 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 coverageAccording the Certificate of Coverage (enclosed) Section 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 MarketplaceFor 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 receivedFor 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 terminationThe 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:am until 5:pm, or you may roach me directly at ###-###-####If you are hearing impaired please call 7-1-Telecommunications Relay Service.Sincerely,

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]

[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: [redacted] I am rejecting this response because: The response is acceptable with one amendmentBecause Coventry failed to respond in a timely manner, a claim from [redacted] Emergency Services in January for $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 creditI 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]

Dear *** [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on May 06, 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 $with an Advance Premium Tax Credit (APTC) of $Starting January 01, 2015, the member was enrolled in a new policy with a premium amount of $with an APTC of $Starting on March 01, 2015, the member was enrolled in a new policy with a premium amount of $with an APTC of $Starting on April 01, 2015, the member was enrolled in a new policy with a premium amount of $with an APTC of $ The member was enrolled in Electronic Funds Transfer (EFT) for her recurring premium paymentsWhen the member was billed for March, the amount drafted was for $262.10, which was incorrectSince the member did not have an APTC for that month, the member had a day grace period to avoid terminationWe reinstated the policy without any lapse in coverage since the member was billed incorrectly for the March premiumThe member is currently paid through February 28, The member owes a total amount of $for March, April and May premiumsThe member can contact Coventry Member Services at ###-###-#### to make a payment I apologize for the difficulties and frustration [redacted] encountered with customer serviceFeedback 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

Dear [redacted] , Thank you for allowing us to address the concerns reported in complaint # [redacted] for [redacted] that was received by us on November 21, 2014, regarding termination of his policy Our Executive Resolution Team researched your concerns, and we would like to share the results of the review with you We reached out to our Enrollment department for assistance during our investigation Our records show that [redacted] had requested termination of his policy by faxing in a request form on October 23, Due to this request, the process was begun to terminate the policy effective October 30, This process was completed on November 6, We were able to locate a phone call from October 29, 2014, that [redacted] had made to stop the termination from occurring Unfortunately, the process had already been started and was not stopped Upon locating that call, we were able to reinstate the policy with no lapse in coverage, as the contact had been made in the same month we received the termination request The reinstatement was completed on November 21, A premium payment was made on November 24, 2014, so the policy is paid through November 30, The premium will need to be collected for December in order for the policy to remain active through the end of the year 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] @aetna.com Regards, Chris B [redacted] Executive Resolution Team

September 26, Dear [redacted] :Your letter of September 18, to Coventry Health Care of Virginia, Inc("Coventry Health Care") was referred to my attention for review and response [redacted] objected to Coventry's original response regarding the cancellation of her policy and the August premium she was charged, Coventry addresses these concerns belowIt was identified Coventry issued an incorrect date on [redacted] 's Certificate of Creditable Coverage (CoCC)However, Coventry will honor the incorrect date and [redacted] will be issued a pro-rated refund of the August premiumBased on the additional documentation Coventry has retroactively terminated [redacted] 's policy effective August 4, Please be advised [redacted] will be without medical insurance August 5, through August 31, 2014.Coventry apologizes for any inconvenience this has caused [redacted] If you have any questions, please contact the Customer Service Department at ###-###-####Sincerely, Teresa EComplaint and Appeal Program

Dear *** [redacted] , Please see our response to complaint # [redacted] for [redacted] that was received by us on March 11, During our investigation, it was determined that a renewal notice was sent to [redacted] to advise of the plan change that took place January 1, Coventry’s system shows the letter was sent September 26, As the proper notification was sent, we are not able to find an error on Coventry’s part and will not be able to refund any portion of the premiums we collected for his coverage for 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] Regards, Chris B [redacted] Executive Resolution Team

I received a letter from Coventry Health Care stating that I had verbally authorized Coventry to debit my bank account on Jan 10-AMIn the letter they list the following items: Payment date - Oct , which happens to be my birthday Payment Amount-$Bank Routing No.- [redacted] 4366, this has some no's that are the same but not in that orderBank Routing Number- **SSN**, Not Even Close Payment Reference **SSN**, don't know what that isThe letter further states that if any of the information is incorrect, I should contact them and correct itI have never had any conversations with Coventry, in fact i've never heard of themI will contact my Bank, my Senator, and my State Attorney GeneralTo report this incident!EMPTOR CAVETE

October 31, 2014Dear [redacted] :Your letter of October 29, to Coventry Health and Life Insurance Company (CHL) HealthAmerica was received in our office, and referred to my attention for review and response.In his objection submitted to the Revdex.com, [redacted] questioned the monthly premium rate assigned to his policyAdditionally, [redacted] advised that he does not want any further investigation into his policy [redacted] ***’s policy terminated with CHL on August 31, 2014.If I may be of any further assistance, please feel free to contact me at ###-###-#### or toll-free at ###-###-####, ext***Sincerely,Shawn MComplaint and Appeal Analyst