Fidelis Care

Fidelis is in receipt of your letter dated December 11, 2015, which was received on December 15, 2015, regarding a complaint filed by [redacted] on behalf of former Fidelis member, [redacted] Ms [redacted] reported that her daughter's coverage was retroactively voided causing claim payments to be retracted from providersMs [redacted] stated that she's receiving letters and bills requesting paymentFidelis investigated the complaint and the results are as follows: On December 18, 2014, due to an administrative error, [redacted] 's Child Health Plus eligibility coverage with Fidelis was terminated retroactively to June 1, as a result of a transaction received from the New York Stateof HealthThe transaction terminated the Child Health Plus coverage and enrolled [redacted] a New York State of Health Qualified Health Plan effective December 1, Since the eligibility was voided, Fidelis sent a refund check # [redacted] in the amount of $to Ms [redacted] for the premium payments madeFidelis contacted its bank and determined that Ms [redacted] cashed the issued check on January 29, On December 23, 2015, Fidelis contacted Ms [redacted] and she has agreed to submit the payment in the amount of $in January Upon receipt of payment, Fidelis will update the eligibility and reprocess all claims received during the enrollment period in questionFidelis apologizes for the inconvenience experienced by Ms [redacted] If you require additional information, please contact me at ###-###-####Sincerely, Reverend Patrick FPresident and Chief Executive Officer

Fidelis is in receipt of your correspondence dated May 1, and received on May 10, 2017, regarding a complaint filed by [redacted] *** on behalf of his wife Fidelis' [redacted] Advantage Flex Plan member, [redacted] ***Mr [redacted] reported that he is looking to be reimbursed for a prescription that was not covered and should be covered per contractFidelis investigated the complaint and the results are as follows: On September 2, 2016, Fidelis received a reimbursement request from Mrs [redacted] for [redacted] She stated that she paid $out of pocket on August 14, [redacted] was a non-formulary medication in and additional information was needed to review the non-formulary exception component of the request prior to reviewing the reimbursement requestFidelis' Pharmacy Services Department made outbound calls and faxes to the provider's office to determine why Ms*** could not be prescribed [redacted] or [redacted] , which were the formulary alternativesOn September 9, 2016, a representative from the provider's office responded stating that the prescriber did not want the patient on any muscle relaxantFidelis denied the non-formulary exception and the reimbursement request was deniedOn September 28, 2016, Mrs [redacted] appealed the reimbursement denial and requested to be reimbursed $J for the medicationShe also requested that Fidelis not contact her provider regarding this requestIn order to review the appeal of the reimbursement denial, the medication had to be first reviewed as a non-formulary medicationA supporting statement was required from the prescriber as to why the member could not be on the formulary alternatives, [redacted] and [redacted] The provider faxed a response stating that the member was prescribed [redacted] on the weekend by an on-call providerThe on-call provider was not aware that the medication was not coveredThe provider stated they are not appealing the denial of the medicationBased on the information received from the provider's office, the non-formulary exception component of the request could not be approved and the reimbursement request was also deniedFidelis apologizes for the inconvenience this may have caused Mrand Mrs ***If you require any additional information, please contact Robert F., Senior Vice President at ###-###-####Sincerely, Reverend Patrick FPresident and Chief Executive Office

I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
The formulary handbook states that a one time exception for a non-compete drug for a continuing member can be covered until an alternative could be prescribedI have repeatedly showed this to management at Fidelis but was never contacted to discussIf this is a *** regulation issue then Fidelis should contact ***Fidelis should have a process to handle this error by a medical professional and not cause the member to not get the benefits as spelled out in Fidelis documentation
Regards,
*** ***

Fidelis is in receipt of your correspondence dated March 28, 2017 and received on April 3, 2017 regarding a complaint filed by [redacted], RN. Ms. [redacted] reported that Fidelis inappropriately denied claims that were billed to Fidelis for over five months and they have not been compensated for...

the services. She also reported paying for medical supplies for the member due to the delay in receiving them. Fidelis investigated the complaint, and the findings are as follow: Fidelis reviewed the claims history for [redacted], R.N. Fidelis determined that [redacted], R.N. requested authorization for nursing services that was approved for a total of 86 hours to be provided between October 1, 2016 and December 31, 2016. Fidelis paid the provider for 86 hours of nursing services during the authorization period, however the provider
billed in excess of the approved hours during the authorization period, and the additional hours were denied appropriately since the provider failed to obtain an authorization for the additional hours. Fidelis reviewed Ms. [redacted] concerns regarding paying for medical supplies due to the delay in receiving them. Fidelis determined no request for medical supplies were received by Ms, [redacted] for Fidelis members. Fidelis covers authorized medically necessary supplies under the Medicaid benefit. Fidelis
recommends that Ms. [redacted] contact Fidelis' Authorization Department for assistance in requesting medical
supplies needed for Fidelis members. Fidelis regrets the inconvenience Ms. [redacted] may have experienced regarding this matter, but the claims were processed appropriately in accordance with the authorization. If you require additional information, please contact Robert F., Senior Vice President at ###-###-####. Sincerely, Reverend Patrick F.  President and Chief Executive Officer

Fidelis is in receipt of your letter dated December 11, 2015, which was received on December 15, 2015, regarding a complaint filed by [redacted] on behalf of former Fidelis member, [redacted]. Ms. [redacted] reported that her daughter's coverage was retroactively voided causing claim payments...

to be retracted from providers. Ms. [redacted] stated that she's receiving letters and bills requesting payment. Fidelis investigated the complaint and the results are as follows: On December 18, 2014, due to an administrative error, [redacted]'s Child Health Plus eligibility coverage with Fidelis was terminated retroactively to June 1, 2010 as a result of a transaction received from the New York Stateof Health. The transaction terminated the Child Health Plus coverage and enrolled [redacted] a New York State of Health Qualified Health Plan effective
December 1, 2014. Since the eligibility was voided, Fidelis sent a refund check #[redacted] in the amount of $720.00 to Ms. [redacted] for the premium payments made. Fidelis contacted its bank and determined that Ms. [redacted] cashed the issued check on January 29, 2015. On December 23, 2015, Fidelis contacted Ms. [redacted] and she has agreed to submit the payment in the amount of $720.00 in January 2016. Upon receipt of payment, Fidelis will update the eligibility and reprocess all claims received during the enrollment period in question. Fidelis apologizes for the inconvenience experienced by Ms. [redacted]. If you require additional information, please contact me at ###-###-####. Sincerely, Reverend Patrick F. President and Chief Executive Officer

Revdex.com received the following response from consumer on behalf of business: This complaint has been resolved, Fidelis activated my childs insurance ratroactivly. Thank you for you help. Sincerely, [redacted]

Fidelis is in receipt of your correspondence dated May 1, 2017 and received on May 10, 2017, regarding a complaint filed by [redacted] on behalf of his wife Fidelis' [redacted] Advantage Flex Plan member, [redacted]. Mr. [redacted] reported that he is looking to be reimbursed for a prescription...

that was not covered and should be covered per contract. Fidelis investigated the complaint and the results are as follows: On September 2, 2016, Fidelis
received a reimbursement request from Mrs. [redacted] for [redacted]. She
stated that she paid $12.00 out of pocket on August 14, 2016. [redacted] was a non-formulary
medication in 2016 and additional information was needed to review the non-formulary exception component of the request prior to reviewing the reimbursement
request. Fidelis' Pharmacy Services Department made outbound calls and faxes to the provider's office to determine why Ms. [redacted] could not be prescribed [redacted] or [redacted], which were the formulary alternatives. On September 9, 2016, a representative from the provider's office responded stating that the prescriber did not want the patient on any muscle relaxant. Fidelis denied the non-formulary exception and the reimbursement
request was denied. On September 28, 2016, Mrs. [redacted] appealed the reimbursement denial and requested to be reimbursed $J 1.26 for the medication. She also requested that Fidelis not contact her provider
regarding this request. In order to review the appeal of the reimbursement denial, the medication had to be first reviewed as a non-formulary medication. A supporting statement was required from the prescriber as to why the member could not be on the formulary alternatives, [redacted] and [redacted]. The provider faxed a response
stating that the member was prescribed [redacted] on the weekend by an on-call provider. The on-call provider was not aware that the medication was not covered. The provider stated they are not appealing the denial of the medication. Based on
the information received from the provider's office, the non-formulary
exception component of the request could not be approved and the reimbursement request was also denied. Fidelis apologizes for the inconvenience this may have caused Mr. and Mrs.
[redacted]. If you require any additional information, please contact Robert
F., Senior Vice President at ###-###-####. Sincerely, Reverend Patrick F. President and Chief Executive Office

Fidelis is in receipt of your letter dated May 19, 2016, which was received on June 1, 2016 regarding a complaint filed by Fidelis member, [redacted]. Ms. [redacted] reported that she enrolled through the New York State of Health (NYSOH) and received a notice from Fidelis advising that her...

monthly premium was due. Ms. [redacted] stated that she immediately paid the monthly premium through the Fidelis Care portal; however she received a termination notice shortly after. Ms. [redacted] requested that Fidelis apply her April premium to the month of May. Ms. [redacted] stated she continued to receive notices advising her that she owes the April premium although she had no coverage. Ms. [redacted] is requesting a refund for the April premium and to terminate her Fidelis coverage, Fidelis investigated the complaint and the results are as follows: On April 6, 2016, Fidelis received a transaction file from the NYSOH enrolling [redacted] into Fidelis' Silver Plan effective April 1, 2016. The enrollment was pending awaiting the initial premium payment, and Fidelis sent Ms. [redacted] a premium notification letter advising that her premium payment was required to effectuate her coverage. Fidelis determined that due to an administrative error the premium payment received on April 17, 2016 was not applied timely. Fidelis agreed to effectuate Ms. [redacted] coverage for May 1, 2016 and applied her premium payment accordingly. Fidelis reviewed Ms. [redacted] premium payment history and determined that she has a premium payment due of $295.39 for the month of July, 2016. Fidelis contacted Ms. [redacted] on June 3, 2016 and she advised th.at she wishes to continue her enrollment through Fidelis. Fidelis apologizes for the inconvenience experienced by Ms. [redacted]. If you require additional information, please contact me at ###-###-####. Sincerely,  Reverend Patrick F. President and Chief Executive Officer

Fidelis is in receipt of your letter dated September 30, 2016, and received on October 10, 2016
regarding a complaint filed by [redacted]. Ms. [redacted] reported that Fidelis terminated her health coverage because her payment was short $0.80. She stated that her husband and two children had no...

coverage due to the shortage in premium payment. Ms. [redacted] is requesting a reinstatement. Fidelis investigated the complaint and the results are as follows: Fidelis received a transaction from the New York State of Health (NYSOH) on August 11, 2016
enrolling [redacted], [redacted], [redacted], [redacted], and [redacted] into Fidelis' Bronze Plan with an Advance Premium Tax Credit (APTC) in the amount of$801.00, effective September 1, 2016. The monthly premium for this plan was $54.80. On August 25, 2016, Fidelis received
a transaction from the NYSOH changing the APTC to $725.00 resulting in a monthly premium of $130.80. The effectuation of the coverage was pending receipt of the initial premium payment. Please note that the member had previous coverage with Fidelis under the Essentila Plan and had unpaid balances for this coverage. On September 7, 2016, Fidelis received a payment in the amount of $130.00 and determined that Ms. [redacted] had an outstanding balance of $54.80, Fidelis applied $34.80 for coverage provided in February 2016 and $20.00 for a balance on the Fidelis Essential Plan for August 2016 leaving a credit of $75.20. Fidelis was unable to effectuate coverage for September's Bronze Plan enrollment because the full premium payment was not received. On September 27, 2016, Ms. [redacted] contacted Fidelis' Member Services Department with an inquiry regarding the cancelation notice and she was advised that the payment received was applied to balances owed for her 2016 coverage, and the remaining amount was not a full premium payment required to effectuate the coverage. Ms. [redacted] requested a refund for the remaining credit. On October 6, 2016, Fidelis issued the refund in the amount of $75.20. Fidelis apologizes for the inconvenience experienced by Ms. [redacted], however Fidelis processed the payment received correctly to her outstanding balance due. Ms. [redacted] can re-enroll through the NYSOH and submit her initial premium payment. If you require additional information, please contact Robert F., Senior Vice President at  ###-###-####. Sincerely, Reverend Patrick F. President and Chief Executive Officer