ELAP Services

February 15, 2017Dear *** ***,This response is in reply to your letter dated February 7, regarding the above-mentioned complaint against ELAP Services, LLC (“ELAP), ELAP is the Designated Decision Maker (the “DDM) for the self-funded *** *** Employee Benefit Plan (“Plan”), and
accordingly, ELAP acts with certain fiduciary authority on behalf of the Plan as governed under the Employee Retirement Income Security Act (“ERISA') of 1974.The complaint alleges that the medical services provided on November 19, were to be covered at 100% and that ELAP had not covered the full cost of the billed chargesIn addition, the customer alleges that she had attempted to contact ELAP to have the remaining funds released.We have reviewed this complaint and deny any wrongdoing by ELAPThe claim in question was paid in accordance with the Plan documents, Per the Summary Plan Description, certain benefits are covered at a specified rate of the Allowable Claim Limits, not of total billed chargesAllowable Claim Limits are defined and explained in the Summary Plan Description for the *** *** Employee Benefit PlanIn this case, the Plan paid 100% of the Allowable Claim Limits as specified in the Plan documentsFurther, the Explanation of Benefits (EOB) received by the customer clearly states that the charges exceeded the Plan’s Allowable Claim Limits, and were therefore denied as stated in the Exclusions and Limitations section of the Stimmary Plan Description.Additionally, ELAP did not receive any communication on this matter until an email from the Plan’s Human Resources (HR) department was sent on the customer's behalf on February 3, Although the claim was reimbursed correctly under the terms of the Plan, and ELAP was not obligated to issue further payment, ELAP agreed to pay the remaining balance to the facility and a check was issued on February 14, (see attached)Only cleven (1i) days elapsed from the time that ELAP received notification of this matter until the date of settlementTherefore, ELAP denies all of the allegations in the complaint and requests that the Revdex.com not enter judgment validating the complaint against ELAP.If you have any questions or need any further information, please feel free to contact the undersigned.Thank you,Joanna SEsqManager, Contracts, Compliance & Appeals

This response is in reply to the complaint dated November 9, 2017 regarding the above-mentioned complaint against ELAP Services, LLC (“ELAP”).  ELAP is the Designated Decision Maker (the “DDM”) for the self-funded [redacted] (“Plan”), and accordingly, ELAP acts with...

certain fiduciary authority on behalf of the Plan as governed under the Employee Retirement Income Security Act (“ERISA”) of 1974. We have reviewed this complaint and deny any wrongdoing by ELAP. The claim in question was paid in accordance with the Plan documents. Per the Summary Plan Description, certain benefits are covered at a specified rate of the Allowable Claim Limits. Allowable Claim Limits are defined and explained in the Summary Plan Description for the [redacted].  In this case, the Plan paid the Allowable Claim Limits as specified in the Plan documents. Further, the Explanation of Benefits (EOB) received by the customer clearly states that the charges exceeded the Plan’s Allowable Claim Limits, and were therefore denied as stated in the Exclusions and Limitations section of the Summary Plan Description. The Allowable Claim Limits are determined using specific metrics that take into account a fair and reasonable reimbursement for the services provided. Although the member did receive a balance bill for the amount determined to be ineligible under the Plan for services rendered in September 2016, the Plan provides for attorneys to represent the members in any dispute of charges. The attorney assigned to represent [redacted] did not send a cease and desist letter to the facility, but rather a letter indicating that [redacted] was represented by an attorney and to direct any communication to the attorney, as well as disputing the charges. After this letter was sent, there were no more communications from [redacted] Clinic regarding the balance, and as such, no indication that the facility was still attempting to collect the disputed balance until [redacted] attempted to make an appointment for her son and was told that there were outstanding charges that needed to be paid before any additional services were rendered. The collection attorney's for the facility stated that there was another balance of $29,000 that was due for claims for [redacted]'s son. However, ELAP never received any bills, either from the facility nor the member, regarding this disputed balance. In an attempt to resolve the issue, ELAP worked worked with the Third-Party Administrator and [redacted] to try to obtain any additional bills and to help schedule her son's appointment. Although all claims were reimbursed correctly under the terms of the Plan, and ELAP was not obligated to issue further payment, especially as many of the claims were physician/professional claims not audited by ELAP, ELAP agreed to pay the remaining balance and the hold has been removed from the account. [redacted]'s son was able to obtain service in November.