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Manual - CHC of the Carolinas - Coventry Health Care

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					Administrative
   Manual
         Table of Contents                                                                  To use this interactive guide, click on a topic to go to the
                                                                                            page. You may also click on a section in the sidebar on the
                                                                                            following pages to go to a different section.



    Key Contact Information ............................................4
    Online Account ManagementSM
       Useful Tools for Plan Administration ...................................5            Premium Billing
    Provider Search                                                                           Accounts Receivable Department ....................................15
       To Search for Providers in the POS/Coventry Preferred                                  Sending Payment to the “Mail To” Address .......................15
       PPO Network ...................................................................6       Premiums Due First Day of the Month .............................15
       To Search for Providers in the Out-of-Area Network                                     Billing Cycle ...................................................................15
       (PPO Plans)......................................................................7
                                                                                              Grace Period ..................................................................15
       Get Directions ..................................................................7
                                                                                              Termination for Non-Payment of Premium........................16
    My Online ServicesSM ..................................................8                  Researching Bills From a Physician, Provider or Hospital........16
    Benefits                                                                                  Appeal Process ..............................................................16
       Schedule of Benefits and Applicable Riders...........................9                 Payment Policy for Nonparticipating Providers ..................16
                                                                                              Medical Emergencies .....................................................17
    Certificate of Coverage
                                                                                              Out-of-Area Coverage ....................................................17
       About the Certificate of Coverage and Agreement...............9
                                                                                              Pre-Existing Condition Exclusion/Creditable Coverage .........18
    Contractual Agreements
                                                                                              How to Clear the Pre-Existing Clause for Members
       About your Contractual Agreements ................................10                   with Group-Sponsored Coverage .....................................18
    Enrollment and Termination Procedures                                                     Sample Billing Statement ................................................20
       Open Enrollment ............................................................11       Explanation of Benefits Statement (EOB)
       Documentation Required to Enroll....................................11                 Definition of an EOB Statement .......................................21
       Open Enrollment Documentation .....................................11                  Sample EOB Statement ..................................................22
       Off-Cycle Enrollment Documentation ...............................12
                                                                                            Claims
       Enrolling a Member ........................................................12
                                                                                              Out-of-Area Services ......................................................24
       Disenrolling a Member....................................................12
                                                                                              Preauthorization .............................................................24
       Copy of Enrollment Forms ...............................................13
                                                                                              Complaint and Appeal Process ........................................24
    Eligibility Provisions                                                                    Claims Address ..............................................................24
       Who is Eligible to Enroll ..................................................14
       Coordination of Benefits..................................................14
                                                                                            COBRA Continuation and Medicare Coverages
                                                                                              COBRA Continuation of Coverage ....................................25
       Qualifying Events and Special Enrollment Periods .............14
                                                                                              Federally Mandated Coverage (COBRA) ...........................25
                                                                                              State-Mandated Coverage ..............................................26
                                                                                              Medicare .......................................................................26
                                                                                              Coordination of Benefits..................................................26
                                                                                              Coordination of Benefits with Medicare
                                                                                              for Members 65 and Over ...............................................27




2                                                 www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
           Table of Contents                                                                   To use this interactive guide, click on a topic to go to the
                                                                                               page. You may also click on a section in the sidebar on the
                                                                                               following pages to go to a different section.



    Wellness
        Coventry WellBeingSM......................................................28
        Mother To BeSM — Helping You Have a Healthy Baby ........28
        Tobacco Cessation .........................................................29
        Diabetes FAQ .................................................................30
        Vision Care ....................................................................31
    Notices
        Your Privacy Matters ..........................................................33
    Forms.................................................................................36
        Enrollment/Change Form: 1-25 Employees
        Enrollment/Change Form: 26+ Employees
        Provider Nomination Form
        Medical Claim Form
        How to complete this Medical Claim Form
        Medco Forms




      Coventry Health Care of the Carolinas, Inc. (“CHC Carolinas”) takes Covered Person concerns, complaints and grievances seriously and has established
      consistent procedures for responding to them. CHC Carolinas has developed complaint resolution, appeal and grievance policies and procedures to provide
      Covered Persons with a mechanism to voluntarily voice their concerns, misunderstandings and/or dissatisfaction with any aspect of CHC Carolinas policies
      and procedures or care rendered by a contracted Provider. For more information, please refer to section 10 of the Certificate of Coverage (COC).



3
Table of Contents         Key Contact Information
Key Contact Information   Customer Service
                          • Claims/benefits                               • Member ID cards
                          • Member verification                           • Deductible information
Online Account            • Provider status                               • Coventry Consumer Choice
                                                                                                                 Phone: 800-935-7284
ManagementSM              • Member appeals                                 (C3) inquiries
                          Enrollment Department
Provider Search                                                           • Status of enrollment forms
                          Coventry Health Care of the Carolinas, Inc.     • Terminations, additions, changes,
                                                                                                                 Phone: 888-296-3337
                          P.O. Box 7751                                     corrections
                                                                                                                 Fax: 866-506-5256
My Online ServicesSM      London, KY 40742                                • Questions about COBRA, HIPAA,
                                                                            & qualifying events
                          Marketing Department
Benefits                  Morrisville Office                              Phone: 919-337-1800 or 866-935-7284
                          2801 Slater Road, Suite 200                     Fax: 919-337-1871
                          Morrisville, NC 27560                           www.chccarolinas.com
Certificate of Coverage   Charlotte Office                                Phone: 704-357-1421 or 800-470-4523
                          2815 Coliseum Centre Drive, Suite 550           Fax: 704-357-3164
                          Charlotte, NC 28217                             www.chccarolinas.com
Contractual Agreements    Columbia, SC Office                             Phone: 803-740-7922 or 866-802-2476
                          140 Stoneridge Drive, Suite 200
                          Columbia, SC 29210                              www.chccarolinas.com
Enrollment and
Termination Procedures    Billing/Payment
                          Billing: Accounts Receivable                                                           Phone: 888-296-3337

Eligibility Provisions    Care Team
                          • Employer group help line with any online account management issue                    Phone: 888-296-3337
                          Prescription Drug Benefits
Premium Billing           • Questions about specific prescriptions                                               Phone: 800-935-7284
                          Prior Authorization
Explanation of Benefits   • Inpatient hospitalizations
Statement (EOB)           • Out-of-network benefits                       Phone: 800-708-9355
                          • Other services
                          Vision
Claims                                                                    Phone: 800-877-7195
                          VSP
                                                                          Go to www.chccarolinas.com to locate a provider
COBRA Continuation and    Mental Health and Substance Abuse
Medicare Coverages                                                        Phone: 866-533-5157
                          Magellan
                                                                          Go to www.magellanassist.com to locate a provider
                          Dental
Wellness
                                                                          Phone: 888-296-3337
                          Coventry Dental
                                                                          www.cvtydental.com
Notices                   Consumer Driven
                          Coventry Consumer Choice (C3)                   Phone: 800-722-1758
                          HSA/HRA/FSA                                     (for broker/employer inquiries)
Forms                     Claims Address
                          Coventry Health Care of the Carolinas, Inc., P.O. Box 7102, London, KY 40742




  4                             www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Online Account ManagementSM

Key Contact Information   Useful Tools for Plan Administration
                          At Coventry Health Care of the Carolinas, Inc. (“CHC Carolinas”), we know administrative needs are different.
Online Account            So we give you a convenient way to manage your group health benefits online. Through a single, password-
ManagementSM              protected website, employers can perform a variety of functions and access a wealth of account information at no
                          additional cost. Online Account Management is available 24 hours a day. It is easy to:
Provider Search             • View up to six months of group statements and group invoices.
                            • View payment history.
My Online Services   SM     • View eligibility information for any employee, and find invoices on which that employee appeared.
                            • Access online bill payment.
Benefits                    • Add a dependent to an employee’s coverage.
                            • Terminate coverage or add employee to the plan.
                            • Update employee demographics.
Certificate of Coverage
                            • Perform a wide variety of functions on behalf of any covered member, including requesting ID cards,
                              updating address/phone, etc. Provisions related to member disenrollment are detailed in the attached
Contractual Agreements        contractual agreement(s) section and/or the Certificate of Coverage.


Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing
                                                                                          To register for Online Account
Explanation of Benefits                                                                   Management, please visit our website
Statement (EOB)                                                                           www.chccarolinas.com, select
                                                                                          “Employers” and click on “Login or
Claims                                                                                    Register Now,” or call 866-667-3059.

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  5                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Provider Search

Key Contact Information   It’s easy for you and your members to find an in-network medical and vision provider using our electronic
                          provider search tool. It contains the names, addresses and phone numbers of our participating providers,
Online Account            hospitals, pharmacies, outpatient facilities and other ancillary providers in our network.
ManagementSM
                          To search for providers in the POS/Coventry Preferred PPO network
Provider Search             • Go to www.chccarolinas.com
                            • Click on “Members” and then the “Learn More Today!” link
My Online ServicesSM        • On the left hand side, click on “Find a Doctor”
                            • Click on “Enter Provider Search” under the caption that says “CHC of Carolinas HMO, Point-of-Service,
                              and Coventry Preferred PPO Plans”
Benefits
                            • Select a product: “Coventry (HMO or POS)” or “Coventry Preferred (PPO)” (these are the same networks)
                            • Search by ZIP code
Certificate of Coverage     • Select the type of provider you are looking for: name, facility, specialty or condition


Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  6                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Provider Search — Continued

Key Contact Information
                          To search for providers in the Out-of-Area Network (PPO OA Plans)
                            • Go to www.chccarolinas.com
Online Account
ManagementSM                • Click on “Members” and then the “Learn More Today!” link
                            • On the left hand side, click on “Find a Doctor”
Provider Search             • Click on “Enter Provider Search” under the caption that says “CHC Carolinas HMO, Point-of-Service, and
                              Coventry Preferred PPO Plans”
                            • Select a product: “Coventry National Network”
My Online ServicesSM
                            • Search by ZIP code
                            • Select the type of provider you are looking for: name, facility, specialty or condition
Benefits


Certificate of Coverage


Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness                  Get Directions
                          Members can obtain a map and driving directions to the provider they’ve selected by simply clicking “display
Notices                   map” next to your chosen health care provider.

                          NOTE: If for some reason you need a printed paper copy of the provider directory, you can call
Forms                     your account manager or Customer Service. Because any paper directory is only as current as the
                          date it was printed, we encourage our members to either call our Customer Service department or
                          log on to our website, if they have any questions about a provider being a part of our network.




  7                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
                          My Online Services
                                                                 SM

Table of Contents


Key Contact Information   Members have access to an electronic personal health assistant, putting them in control of their health and
                          benefits. Within My Online Services, members can find complete, personalized information that is built around a
Online Account            personal health record (PHR).
ManagementSM
                          Personal Health Record
                            • View, store, track and maintain personal health information
Provider Search
                            • Share with a health care provider, family member or caregiver

                          Transactions
My Online ServicesSM
                            • View medical and prescription claims
                            • View or print explanations of benefits
Benefits
                            • View, request or print an image of an ID card
                            • Send a secure email to CHC Carolinas
Certificate of Coverage     • Update personal information

                          Health and wellness
Contractual Agreements      • Take a health risk assessment
                            • Request an email reminder for screenings and tests
Enrollment and
Termination Procedures      • Access Coventry WellBeingSM with a wealth of online wellness programs

                          Cost and Quality tools
Eligibility Provisions      • Search for network providers
                            • Save on prescription drugs                                    Here’s how to register for
Premium Billing             • Compare hospital quality ratings                              My Online ServicesSM:
                                                                                            1. Visit the web address on the
Explanation of Benefits                                                                        member ID card.
Statement (EOB)
                                                                                            2. Select the “Members” menu.
Claims                                                                                      3. Click “Login/Register” on the
                                                                                               Member home page.
COBRA Continuation and
Medicare Coverages                                                                          4. Click “Register Now.”
                                                                                            5. Follow the instructions given to
Wellness                                                                                       register. Even if you are a current
                                                                                               user you will need to register.

Notices


Forms




  8                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Benefits

Key Contact Information   Schedule of Benefits and Applicable Riders
                          These documents inform your employees about their benefits and out-of-pocket costs. We have included
Online Account            the schedule(s) of benefits and any applicable riders your company chose for its health care benefit plan as
ManagementSM              attachments in your electronic welcome kit.

Provider Search


My Online ServicesSM


Benefits


Certificate of Coverage
                          Certificate of Coverage
Contractual Agreements

Enrollment and            About the Certificate of Coverage and Contract Agreement
Termination Procedures    In general, the Certificate of Coverage explains to your employees how to access their covered services. The
                          Group Contract Agreement is the legal agreement between the contract holder and CHC Carolinas, for the
                          provision and receipt of covered services. This agreement describes the benefits, exclusions, and limitations,
Eligibility Provisions
                          terms, conditions and scope of their coverage.

Premium Billing           Important Notice!
                          It is important that you and your employees become familiar with this document. The North Carolina
Explanation of Benefits   Department of Insurance considers this Group Membership Agreement to be the legal document
Statement (EOB)           that your employees and their family dependents are bound by law to follow.

Claims                    Certificates of Coverage are provided along with your benefit information.

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  9                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Contractual Agreements

Key Contact Information
                          About your Contractual Agreements
                          The contractual agreement(s) detail the following:
Online Account
ManagementSM                • Coverage under your health care benefit plan
                            • Coverage effective date
Provider Search             • Eligibility for coverage
                            • Group enrollment waiting period
My Online Services   SM
                            • When monies are due
                            • How agreement(s) may be terminated
Benefits
                          We have included in your welcome kit a copy of the contractual agreement(s) signed by your local
                          CHC Carolinas Chief Executive Officer.
Certificate of Coverage


Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  10                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Enrollment and Termination Procedures

Key Contact Information
                          Important Notice!
                          The enrollment and disenrollment procedures that follow are standard for all CHC Carolinas customers.
Online Account
                          The procedures specific to your company are detailed in the Contractual Agreement(s) attachment
ManagementSM
                          received in your welcome kit.

Provider Search
                          Open Enrollment
                          It is important that you understand the difference between an open enrollment period and an off-cycle
My Online ServicesSM      enrollment:

                            • An open enrollment period is the time period designated by your company when eligible employees
Benefits                      are offered the option to choose, change or reallocate benefits. This is usually once a year, in the month
                              preceding your contract anniversary.

Certificate of Coverage     • Off-cycle enrollment are those days not designated by your company as part of the open enrollment
                              period. Enrollment would only be allowed if a qualifying event occurs.

Contractual Agreements    Documentation Required to Enroll
                          Employees and eligible family dependents may enroll during the open enrollment period or during the off-cycle
Enrollment and            enrollment.
Termination Procedures
                          CHC Carolinas offers two ways to enroll new employees and their dependents:

Eligibility Provisions    1. Use our convenient online system through Online Account ManagementSM. It’s free and
                             simple to use!

                          OR:
Premium Billing
                          2. Mail or fax a signed, completed paper enrollment/change form to us. Address and
Explanation of Benefits      fax information is located on page four of this manual.
Statement (EOB)

                          Open Enrollment Documentation
Claims
                          To enroll your employees and their eligible family dependents during the open enrollment period, you must
                          submit to the CHC Carolinas Enrollment department, a completed enrollment/change form for each employee
COBRA Continuation and    and his or her family dependents. For detailed information about this section, please see Section 2 of the
Medicare Coverages        Certificate of Coverage, entitled “Enrollment and Eligibility.”

                          	 •	 When the employee enrolls a disabled dependent. The subscriber must submit an enrollment/change
Wellness                       form. An additional form must be completed and signed by the disabled dependent’s attending physician,
                               describing the disability. Your account manager can provide you with this form. We reserve the right to
Notices                        periodically review the eligibility of disabled dependents.

                          There are also some uncommon circumstances that occur with an employee and/or family dependent who
                          wishes to enroll during the open enrollment period. When these uncommon circumstances occur, your account
Forms
                          manager may ask you to submit documents other than those listed above.




  11                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Enrollment and Termination Procedures — Continued

Key Contact Information
                          Off-Cycle Enrollment Documentation
                          The eligibility provisions as they relate to off-cycle enrollment for new and existing employees and their eligible
Online Account            family dependents, new spouse, newborn, adopted or stepchild are detailed in your contractual agreement(s)
ManagementSM              and/or the Group Membership Agreement.

Provider Search           Enrolling a Member
                          As your company’s benefit administrator, you have a significant role in the enrollment process. It is important that
My Online Services   SM   you understand and follow it. CHC Carolinas will not accept any retroactive enrollments beyond 31 days of
                          the date of the enrollment.
                          You distribute enrollment packets to eligible employees during the open enrollment period. (Your service
Benefits                  representative will be happy to distribute these packets for you at enrollment meetings during the open enrollment
                          period). The enrollment packets contain a group enrollment form, schedule of benefits and applicable riders.
                          The six-step enrollment process is as follows:
Certificate of Coverage
                          1. Each employee and his or her dependents carefully reviews the information in the enrollment packet.

Contractual Agreements    2. The employee completes and submits to you an enrollment form and any additional documentation that is
                             required, as explained in the previous section, “Documentation Required to Enroll.”
Enrollment and            3. You review the enrollment form to ensure that it is completely filled out. Also, you need to make sure the
Termination Procedures       employee has signed the enrollment form and to make sure any additional required documentation is attached
                             to the enrollment form. (Please verify that the employee’s hire date, group number and group name are listed
Eligibility Provisions       on the form.)

                          4. After ensuring the enrollment form is complete and any additional documentation is attached to it, submit
                             all documentation to CHC Carolinas’s Enrollment department (see Key Contact Information page for fax
Premium Billing              number). You may also submit the information yourself if you have access to CHC Carolinas’s Online
                             Account ManagementSM website. If you are interested in signing up for this service, please read the attached
Explanation of Benefits      documentation.
Statement (EOB)
                          5. The Enrollment department will verify the data from the enrollment form and enter the data into our system for
                             you if you do not have access to Online Account Management.
Claims
                          6. CHC Carolinas mails each employee and each family dependent an identification card (ID). In the unlikely
                             event a member does not have his or her identification card by the first day of coverage, the member can
COBRA Continuation and
                             request a copy of a temporary ID card.
Medicare Coverages
                          *Please note: Newborn coverage must be added within 31 days of the birth of the newborn in order for
                          benefits to be paid, even if family coverage is already in place.
Wellness


Notices                   Disenrolling a Member
                          As your company’s benefit administrator, you are responsible for notifying our Enrollment department when you
                          disenroll an employee or a family dependent. To do this, simply complete Section A, B and D of the enrollment
Forms                     form for processing. It is important that you understand and follow this disenrollment process. CHC
                          Carolinas will not accept any retroactive disenrollments beyond 31 days of the date of the member’s
                          disenrollment.



  12                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Enrollment and Termination Procedures — Continued

Key Contact Information   CHC Carolinas may generally disenroll employees and family dependents when the employee and/or family
                          dependents:
Online Account
                            • Fail to pay all copayments, coinsurance, deductibles, penalties, and premium contributions and bills for
ManagementSM
                              unauthorized or uncovered services.
                            • Misuse the member identification card.
Provider Search
                            • Fail to cooperate with the coordination of benefits.
                            • Do not maintain a satisfactory physician/patient relationship.
My Online ServicesSM
                            • Become ineligible for benefits.

                          Provisions related to member disenrollment are detailed in your contractual agreement(s) and/or the Group
Benefits                  Membership Agreement.


Certificate of Coverage   Copy of Enrollment Forms
                          An electronic version has been provided for you to use. You should save this document and print the enrollment
                          forms as needed.
Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  13                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Eligibility Provisions

Key Contact Information
                          Who is Eligible to Enroll
                          Please review this section of your agreement or Certificate of Coverage carefully. Failure to abide by eligibility
Online Account
                          provisions may result in loss of coverage for an employee and his or her family dependents. This section includes
ManagementSM
                          the following important information:
                            • Who is eligible to enroll in your company’s health care benefit plan
Provider Search
                            • When coverage begins for enrolled employees and their family dependents

My Online ServicesSM      Coordination of Benefits
                          If the member’s spouse and/or dependents are covered by CHC Carolinas or CHL in addition to being covered
                          by a separate group health plan, both plans will be coordinated so that up to, but no more than, 100 percent
Benefits                  of the eligible expenses will be paid. Information regarding other insurance carriers must be completed by the
                          employees using the enrollment/change form. Information regarding any changes or additions of group health
                          plans should be supplied to CHC Carolinas immediately by contacting the Customer Service department.
Certificate of Coverage
                          Qualifying Events and Special Enrollment Periods
Contractual Agreements    New subscribers may enroll and dependents may be added if any of the following events occur:
                            • Birth of a child
Enrollment and              • Adoption of a child or placement for adoption or foster care*
Termination Procedures      • A Qualified Medical Child Support Order (QMCSO)*
                            • Marriage*
Eligibility Provisions      • Termination of spouse’s employment, or a change in employee’s, subscriber’s or spouse’s employment
                              status from full-time to part-time status or vice versa*
Premium Billing             • Employer’s or subscriber’s involuntary loss of other health coverage except for failure to pay premium or for
                              cause (e.g., material misrepresentation of fact)*
                          *Supporting documentation of these events is required and must be submitted with an
Explanation of Benefits
                          Enrollment/Change Form.
Statement (EOB)
                          CHC Carolinas requires that subscribers complete a new Enrollment/Change Form to report changes that affect
                          their coverage. (This may be in addition to any forms required by the group.) Online Account ManagementSM also
Claims                    may be used, but will only allow enrollment or termination within 31 days of the qualifying event.
                          Any Enrollment/Change Form must be received by CHC Carolinas within 31 days of the qualifying event or the
COBRA Continuation and    date specified in the Group Application/Renewal Confirmation. Coverage will be retroactive to the date of the
Medicare Coverages        change. For marriage, a subscriber’s spouse can either be added on the date of marriage or the first day of the
                          following month, whichever the subscriber specifies. Any eligible dependents that are not enrolled during this
                          time will not be eligible for enrollment until the next open enrollment period. Please refer to your Evidence of
Wellness
                          Coverage/Certificate of Coverage/Certificate of Insurance or other Plan Document for further details.

Notices                   Important Notice!
                          The eligibility provisions specific to your company are detailed in the Contractual Agreement(s) and/or
Forms                     the Certificate of Coverage and Group Contract Agreement attachments to this welcome kit.




  14                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Premium Billing

Key Contact Information
                          Important Notice!
                          The billing provisions that follow (i.e., the premium due date, billing cycle, grace period and termination
Online Account
                          provisions) are standard among all of our customers.
ManagementSM
                          The billing provisions specific to your company are detailed in the Group Contractual Agreement(s)
                          attached to your welcome kit.
Provider Search

                          Accounts Receivable Department
My Online ServicesSM
                          The address and phone number of the Accounts Receivable department is listed in the Key Contact Information
                          in the front of this manual. Your accounts receivable representative is available to answer any questions you may
                          have regarding your bill. You should also contact your accounts receivable representative if you are unable to pay
Benefits
                          your premium on time.
                          He or she will work with you to help you rectify any problems you are having paying your bill on time.
Certificate of Coverage
                          Sending Payment to the “Mail To” Address
Contractual Agreements    Your payment check must be sent with the remittance copy. If you have any member terminations, you can
                          terminate coverage for these employees and have your bill automatically adjusted if you use our Online Account
Enrollment and            ManagementSM tool.
Termination Procedures    If you are not using Online Account Management, please pay as billed. You will need to submit your terminations
                          on paper via mail or fax. Please do not submit employee or dependent terminations when you mail your
                          payment. This will cause a delay in processing and the termination you submitted may not appear on your next bill.
Eligibility Provisions
                          Please mail premium payments to:              HMO/POS:                       PPO:
Premium Billing           Coventry Health Care                          Coventry Health Care of the    Coventry Health and Life Insurance
                          of the Carolinas, Inc.                        Carolinas, Inc.                Company
                          P.O. Box 932422                               P.O. Box 6526                  P.O. Box 6487
Explanation of Benefits   Atlanta, GA 31193                             Carol Stream, IL 60197         Carol Stream, IL 60197-6487
Statement (EOB)

                          Premiums Due First Day of the Month
Claims
                          CHC Carolinas’s plans are “prepaid plans.”

COBRA Continuation and    You have agreed to prepay your monthly premium on or before the first day of the upcoming month.
Medicare Coverages
                          Billing Cycle
Wellness                  Your bill is prepared on or about the ninth day of the month, preceding the month for which premium is due. If
                          you do not receive your bill by the first day of the month, or if you have any questions regarding your bill, call
                          your accounts receivable representative (the phone number can be located on the Key Contact Information page
Notices                   located in the front of this manual).

Forms                     Grace Period
                          Provisions related to the grace period are detailed in the Contractual Agreement(s) and/or Certificate of Coverage
                          attached to your welcome kit.



  15                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Premium Billing — Continued

Key Contact Information
                          Termination for Non-Payment of Premium
                          When termination occurs because of nonpayment of premium, it is your responsibility, as your company’s
Online Account            benefit administrator, to notify those employees with CHC Carolinas coverage that their coverage is terminated.
ManagementSM              These employees, and their family dependents, are liable for payment of any applicable share of coinsurance,
                          copayments and premium owed. We are liable for claims incurred prior to the date of termination.
Provider Search
                          Researching Bills From a Physician, Provider or Hospital
My Online Services   SM
                          Any bill or statement a member receives should be reviewed carefully. If the member does not understand the
                          purpose of the bill or statement, he or she should contact the provider’s office. Members can also login to the
                          website at www.chccarolinas.com to access My Online ServicesSM and view the status of claims. Customer
Benefits                  Service can also assist by researching the payment status of a claim. In the event that you are asked by the
                          member to investigate a claim or coverage issue on his/her behalf, you should direct him/her to the website or
                          to Customer Service. If a member is unable or unwilling to follow this procedure, ask the member to complete
Certificate of Coverage   a member designated release form. A signed member designated release form must be submitted to CHC
                          Carolinas before information can be released to you. The Authorization Statement allows CHC Carolinas to
                          release certain confidential information to you at the specific written request of the member.
Contractual Agreements

Enrollment and
                          Appeal Process
Termination Procedures    If a member is unable to resolve a claim or other problems related to benefits or coverage, an appeal process
                          coordinated through Quality Management is available. Please refer to the Evidence of Coverage/Certificate
                          of Coverage/Certificate of Insurance or other Plan Document for a complete description of the complaint and
Eligibility Provisions    appeal process.
                          Members should submit their written requests describing their concerns and desired outcomes to:
Premium Billing             Coventry Health Care of the Carolinas, Inc.
                            Attn: Member Grievance Department
Explanation of Benefits     2801 Slater Road, Suite 200
Statement (EOB)             Morrisville, NC 27560
                          The member may contact Customer Service for a description of the complete process at any time.
Claims
                          Payment Policy for Nonparticipating Providers
COBRA Continuation and    In many instances, when a member sees a nonparticipating provider for covered care, CHC Carolinas will reimburse
Medicare Coverages        the claim directly to the subscriber on the policy. The subscriber will then be responsible for paying the provider.
                          The amount of the payment will be the same as if the provider were paid directly. This policy applies to claims
                          from any nonparticipating physician or professional provider within the geographic areas where CHC Carolinas has
Wellness
                          participating providers.* CHC Carolinas will continue to make payments to nonparticipating hospitals for covered
                          services.
Notices                   Members’ access to non-participating providers remains unchanged. For example:

                            • HMO members may receive pre-approved care from nonparticipating physicians.
Forms                       • POS and PPO members may choose to see nonparticipating physicians and receive out-of-network benefits.

                          CHC Carolinas will continue to accept claim forms directly from any provider.




  16                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Premium Billing — Continued

Key Contact Information   The member receives an Explanation of Benefits, which shows the provider name, date of service, services
                          provided and amount of payment for each service. Claims for HMO members receiving preapproved care will be
Online Account            covered in full less any required copayment, deductible or coinsurance. POS members receiving out-of-network
ManagementSM              benefits need to pay the provider applicable deductibles, copayments, coinsurance and amounts over CHC
                          Carolinas’s allowed amount, in addition to CHC Carolinas’s payment.
Provider Search           *Excludes members covered by PPO products.


My Online ServicesSM
                          Medical Emergencies                                           IMPORTANT FACTS
                          A medical emergency is the sudden onset of             Examples of a medical emergency are:
                          a medical condition, such as unusually severe
Benefits                  symptoms. Immediate medical attention                  • Trouble Breathing
                          should be sought if the condition could result         • Loss of consciousness
                          in serious jeopardy to the mental or physical
                                                                                 • Severe or unusual bleeding
Certificate of Coverage   health of the member, danger of serious
                          impairment of the member’s bodily functions,           • Suspected poisoning
                          serious dysfunction of any of the member’s             • Obvious broken bones
Contractual Agreements    bodily organs, or in the case of a pregnant            • Serious burns
                          woman, serious jeopardy to the woman or her            • Convulsions
                          unborn child.
Enrollment and                                                                   • Prolonged or repeated seizures
Termination Procedures    CHC Carolinas acknowledges, supports and
                                                                                 • Any vaginal bleeding during pregnancy
                          pays for prudent emergency care. Members
                          are covered for emergency care, as described           • Sudden onset of severe pain
Eligibility Provisions    below, anytime, anywhere in the world.
                          Preauthorization is not required for a medical
                          emergency. However, follow-up care for emergencies must be coordinated by the member’s PCP (if applicable)
Premium Billing
                          and appropriate authorization must be obtained prior to treatment.
                          If the services of a specialist are required, the member should make every effort to be treated by a participating
Explanation of Benefits   specialty physician. Should a member seek emergency room services or require inpatient care, CHC Carolinas
Statement (EOB)           should be notified within 24 hours of admission or by the next business day. Please refer to your Evidence of
                          Coverage/Certificate of Coverage/Certificate of Insurance or other Plan Document for a more detailed description
Claims                    of emergency procedures.


COBRA Continuation and    Out-Of-Area Coverage
Medicare Coverages
                          Only true medical emergencies are covered at the emergency room. Examples of medical emergencies include
                          trouble breathing, unconsciousness and severe bleeding. All members are covered at the in-network level
Wellness                  for true medical emergencies when traveling outside of the service area. Once stabilized, if additional care is
                          needed, CHC Carolinas can arrange for care to be provided within the service area.
                          Out-of-area urgent care is defined as the initial treatment of an unexpected acute illness or injury for which a
Notices
                          member cannot reasonably return to the service area for treatment. When a member receives true urgent care
                          services outside of the service area, the in-network urgent care benefit applies. Examples of urgent care include
Forms                     suspected fractures and cuts requiring stitches. Urgent care must be provided in an urgent care center and not
                          in a hospital emergency room.
                          To locate an out-of-area physician the member may contact Customer Service at the number located on the
                          back of the ID card.


  17                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Premium Billing — Continued

Key Contact Information
                          Pre-Existing Condition Exclusion/Creditable Coverage
                          This Plan imposes a pre-existing condition exclusion for any member age 19 and over. This means that if the
Online Account            member has a medical condition before joining this Plan, the member might have to wait a certain period
ManagementSM              of time before the Plan will provide coverage for that condition. This exclusion applies only to conditions for
                          which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period.
Provider Search           Generally, this six month period ends the day before coverage becomes effective. However, if the member was
                          in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. The
                          pre-existing condition exclusion does not apply to pregnancy nor to an employee’s child who is enrolled in the
My Online ServicesSM      Plan within 31 days after birth, adoption, or placement for adoption.
                          This exclusion may last up to 12 months from the member’s first day of coverage, or, if the member was
                          in a waiting period, from the first day of the waiting period. However, the member can reduce the length of
Benefits
                          this exclusion period by the number of days of the member’s prior “creditable coverage.” Most prior health
                          coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if the member
                          has not experienced a break in coverage of at least 63 days. To reduce the 12-month exclusion period by the
Certificate of Coverage
                          employee’s creditable coverage, the member should give CHC Carolinas a copy of any certificates of creditable
                          coverage. If the employee does not have a certificate, but he/she does have prior health coverage, CHC
Contractual Agreements    Carolinas will help the employee obtain one from the employee’s prior plan or issuer.


Enrollment and            How to Clear the Pre-Existing Clause for Members with
Termination Procedures
                          Group-Sponsored Coverage
                          There are three ways to clear the pre-existing clause for a member. The guidelines below apply to all employer
Eligibility Provisions
                          group-sponsored health plans. These guidelines do not apply to CoventryOne individual members.

                          1. Provide proof of creditable coverage: The best and most effective way to clear the pre-existing clause is
Premium Billing              with the submission of the member’s previous carrier’s Certificate of Creditable Coverage. Provided the previous
                             coverage was in place for at least one year and provided that there was no more than a consecutive 63-day
Explanation of Benefits      break in coverage, we can clear the member’s pre-existing clause. If the member was covered for less than a
Statement (EOB)              year, he or she should still submit the Certificate of Creditable Coverage and we will reduce the year-long pre-ex
                             exclusion period by the amount of time that they were actively covered under the previous carrier.
Claims                    NOTE: the 63 consecutive day window above is a key component. If the insurance policies have
                          greater than a 63-day gap in coverage, we will be unable to accept the previous carrier’s Certificate
                          of Creditable Coverage. However, if the new member is a newly hired employee of the group, the
COBRA Continuation and
                          employer’s waiting period is creditable. Please contact Customer Service at 800-935-7284 for further
Medicare Coverages
                          information.

Wellness                  2. Provide medical records: If the member is unable to provide a valid Certificate of Creditable Coverage, the
                             member can submit a copy of medical records. To clear pre-ex, we require a copy of ALL medical records
                             for the six month period ending with the member’s enrollment date with CHC Carolinas. The member would
Notices                      have to obtain records from each medical provider seen during that period and submit them for review with
                             CHC Carolinas’s health services department.

Forms                     3. Provide a written statement: If the member did not have prior coverage, and if they had no medical
                             services in the six-month period prior to their enrollment date with CHC Carolinas, the member will need to
                             write and sign a letter advising that they had no medical services during that six-month period.




  18                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Premium Billing — Continued

Key Contact Information   The enrollment date, referred to above, is the earlier of:
                          1. The first (1st) day of Coverage under this Agreement; or,
Online Account
                          2. The first (1st) day of the waiting period if the group contract imposes a waiting period
ManagementSM
                          Only the submissions of a valid Certificate of Creditable Coverage will guarantee that the pre-existing clause is
Provider Search           waived. The submission of medical records of the letter advising that the member had no medical services will
                          be reviewed by CHC Carolinas’s Health Services department. Depending upon the information submitted, the
                          pre-existing clause may or may not be waived.
My Online ServicesSM      SUMMARY: The submission of a valid Certificate of Creditable Coverage is the best option because it removes
                          the pre-existing clause and the member will never have to deal with it again. Submission of medical records
                          or a letter advising there were no medical services, at best, will only partially clear the member for diagnoses
Benefits                  billed on previously submitted and denied claims. The member needs to be aware that it is possible that
                          another claim will be submitted after the review is complete and the claim may deny for pre-ex, if billed with
                          a different pre-ex diagnosis. However the solution is simple. The member would need to call in and request a
Certificate of Coverage   review of the previously submitted records or letter.
                          For new groups and renewal years immediately following September 23, 2010, CHC Carolinas will not
Contractual Agreements    impose a pre-existing condition exclusion period for enrollees under age 19.
                          All questions about the pre-existing condition exclusion and creditable coverage should be directed
Enrollment and            to Member Services. North Carolina members call 800-935-7284. South Carolina members call
Termination Procedures    888-935-7284.


Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  19                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Sample Billing Statement

Key Contact Information

Online Account                                   HOW TO READ YOUR PREMIUM INVOICE
ManagementSM                                                                                                                                                                                                                                                            1   This is an example
                                                                                                                                                                                                                                                                            of your group number
                                                                                                                                                                         Group Number:                          1234567890
                                                                                                                                                                                                                                                                            & pertinent invoice
Provider Search
                                                                                                                                                                         Invoice Number:                        1234567
                                                                                                                                                                         Invoice Date:                          06/01/2006     1                                            information that should
                                                                                                                                                                         Due Date:                              07/01/2006
                                                                                                                                                                         Coverage Period:                       07/01/2006 to 7/31/2006                                     be referenced when
                                                                                                                                                                         Please make check payable to:                                                                      making payments if you
                                                                                                                                                                                                                                                                            choose to not use the
My Online Services   SM                     00005464
                                            CONTACT NAME
                                                                                  598                101464
                                                                                                                                                                         Health Plan
                                                                                                                                                                         PO BOX 11111
                                                                                                                                                                         CITY ST 12345-1234
                                                                                                                                                                                                       2                                                                    coupon provided.
                                            1234 MAIN STREET
                                            ANYTOWN USA 12345-0000
                                                                                                                                                                                                                                                                        2   The lockbox address
                                                                                                                                                                                                                                                                            you should use to mail

Benefits                                                                                                                                                                                                                                                                    in premium payments.

                                                                                                                                                                                                                                                                        3   Account Summary –
                                       Prior Account                            Payments                         Health Plan                         Current Month                           Retro Premium                               *
                                                                                                                                                                                                                                             Account
                                          Balance                               Received                         Adjustments                           Premium                                    (+/-)                                      Balance                        A summary of payments
                                          $129,822.00                           $129,304.00                             $0.00                          $164,879.00                                $10,489.00                            $175,886.00                         and/or adjustments
Certificate of Coverage                                                                                                     Account Summary
                                                                                                                                                                                                                                                                            applied to your
                                     Prior Month Transactions                                                                                       Date                                                                     Totals
                                                                                                                                                                                                                                                                            account since the
                                     Prior Month’s Statement Balance                                                                              05/09/06                                                            $ 129,822.00                                          last invoice period.
                                     Payment Received Since Last Statement                                                                        05/09/06                                                            $ 64,177.00
                                     Payment Received Since Last Statement                                                                        05/14/06                                                            $ 65,127.00 3
                                                                                                                                                                                                                                                                        4   New Charges for
Contractual Agreements
                                     Health Plan Adjustments                                                                                                                                                          $              0.00
                                  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                     Unpaid Balance From Prior Periods                                                                                                                                                $          518.00
                                     New Charges for Coverage Period                                                                      Premium Detail                                                                                                                    Coverage Period –
                                       16         E3                                                                                         $ 35,737.00
                                       20         FAM                                                                                        $ 37,649.00
                                                                                                                                                                                                                                                                            Premium charges
                                       30         E1                                                                                         $ 48,094.00                                                                                                                    for the CURRENT
Enrollment and
                                       11         EMP                                                                                        $ 23,814.00
                                       16         E&SP                                                                                       $ 19,585.00                                                                                                                    coverage period.
                                       94         Total Contracts                                                                                                                                                     $ 164,879.00 4

Termination Procedures            -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------



                                    Retro Active Charges for Prior Period                                                                                                                                             $     10,489.00            5
                                                                                                                                                                                                                                                                        5   Retro Active Charges
                                                                                                                                                                                                                                                                            for Coverage Period –
                                    Current Monthly Charges                                                                                                                                                           $ 175,368.00               6                          Premium charges/credits

Eligibility Provisions              *Account Balance – Payment Due                                                                                                                                                    $ 175,886.00               7                          for PRIOR periods that
                                                                                                                                                                                                                                                                            have not been billed to
                                  *This is the balance of your account. Payments remitted, adjustments made or enrollment changes not reflected on this invoice will be
                                  reflected on your next statement. Please verify the date of your last payment to determine if you should pay the Account Balance or                                                                                                       you on previous invoices.
                                  Current Month Premium Due. Complete the attached A/R Transmittal form to submit terminations. Credits for those terminations will be
                                  applied against your next statement amount.
                                                                                                                                                                                                                                                                        6   Current Monthly
Premium Billing                   Come visit our website at www.cvty.com.
                                                                                                                                                                                                                                                                            Charges – This amount
                                                                                                                                                                                                                                                                            represents the total
                                                                                                                                  CUSTOMER COPY                                                                                                                             monthly charges for

Explanation of Benefits                                                                                                                                                                                                                                                     this particular coverage
                                                                                                                                                                                                                                                                            period (Items 4
Statement (EOB)                                                                                               00250676300000003155589                                                                                                            Page 3 of 6
                                                                                                                                                                                                                                                                            & 5 combined).

                                                                                                                                                                                                                                                                        7   Account Balance-
                                                                                                                                                                                                                                                                            Payment Due – This
Claims                         We are also here 24 hours a day to service you at www.cvty.com                                                                                                                                                                               is the amount you owe,
                               where in a personalized, secure environment you can:                                                                                                                                                                                         less any payments not
                                                                                                                                                                                                                                                                            reflected in Item 3 above.
                               • View and Print Your Invoice
COBRA Continuation and
                               • Review Your Covered Employees/Dependents
Medicare Coverages             • Add, Remove or Change Covered Employees/Dependents
                               So, come check us out soon!

Wellness


Notices


Forms




  20                       www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Explanation of Benefits Statement (EOB)

Key Contact Information
                          Definition of an EOB Statement
                          The EOB statement is a document that gives members a detailed description of how their claim was processed.
Online Account
ManagementSM              A subscriber will only receive an EOB statement if the the member was responsible for payment, in the form of
                          deductible, coinsurance, penalty or full payment.
Provider Search           NOTE: EOBs are available on My Online ServicesSM.


                          Sample EOB Statement
My Online ServicesSM
                          A sample EOB statement is on the following page.
                          The statement provides an explanation of each section of the statement.
Benefits


Certificate of Coverage


Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  21                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Sample EOB Statement

Key Contact Information

Online Account
ManagementSM
                                  HOW TO READ YOUR
                                  EXPLANATION OF BENEFITS (EOB)
                                  What is an Explanation of Benefits (EOB)?                                                                                                                           Is an Explanation of Benefits (EOB) a bill?
Provider Search                   An EOB is a notification from Coventry Health Care explaining                                                                                                       No, the health plans of Coventry Health Care do not bill members
                                  how your medical claim(s) are processed (including a payment                                                                                                        for medical services. Rather, the health plans process and pay the
                                  adjustment or denial).                                                                                                                                              claims submitted from your provider, facility or hospital.

My Online ServicesSM                                                                                                    If you have questions, call the customer service number printed on your ID card.

                                  1         Address – address to which the EOB was mailed.                                                         3       Important messages from your health                                     Member Responsibility – The amount the member may
                                                                                                                                                           plan. If there is no message this area will be                          be responsible to pay the provider. This amount is not
                                  2         Payments made on behalf of – The Coventry                                                                      blank.                                                                  payable to the Coventry Health Care plan. If payment
                                            subsidiary paying your medical claim. If your                                                                                                                                          was made at the time of service, this may not be applicable.
Benefits                                    employer is a self-funded group, their name will
                                            appear here.
                                                                                                                                                   4       Claim Number – Document control number
                                                                                                                                                           generated by Coventry Health Care. Please
                                                                                                                                                                                                                                   Please contact your provider for clarification.
                                                                                                                                                           reference this number when calling a member                         5   Provider – The name and billing address of the health care
                                            Insured – The person who holds the policy with                                                                 service representative to discuss the claim.                            provider that rendered your medical service. This could be
                                            the insurer.                                                                                                                                                                           an individual practice or facility.
                                                                                                                                                           Paid to Provider, Paid to Member & Paid
                                            Patient – The person who received medical                                                                      to Other – Entities to which the Coventry                               Patient Account # – The patient’s identification number
Certificate of Coverage                     services.                                                                                                      Health Care plan paid dollars.                                          assigned by your health care provider.
                                            Group Name – The policy holder’s employer group.                                                               Total Plan Paid – Total benefit paid by                             6   Date – The date(s) of your medical service(s).
                                            ID Number – The patient’s identification number                                                                the Coventry Health Care plan for services
                                                                                                                                                           rendered.                                                               Procedure Code/Description – The health care industry
                                            assigned by your health plan.                                                                                                                                                          code and description of services performed and billed by
Contractual Agreements                      Date – the date(s) of your medical service(s).                                                                                                                                         your health care provider.
                                                                                                                                                                                                                                   Billed Amount – The total dollar amount billed to your
                                                                  P7701028001
                                                                                                                                                                                                                                   Health Plan by your health care provider for the services they
                                      P7701028001
                                      Page 1 of 1                                                                                                                                             1970000000000                        rendered.
Enrollment and
                                                         COVENTRY HEALTH CARE, INC.
                                                         Administered by Coventry Health Care, Inc
                                                         6705 ROCKLEDGE DRIVE, SUITE 900                                                                                                                                           Contractual Adjustment – Reductions in payment due
                                                         BETHESDA, MD 20817-1850                                        WHITE STOCK
                                                                                                                                                                                                                                   to contracts with your health care provider, coordination of
Termination Procedures                                    Electronic Service Requested
                                                                                                                          201112012054
                                                                                                                          IO                               THIS IS NOT A BILL
                                                                                                                                                     EXPLANATION OF BENEFITS                                                       benefits or non-covered services that may/may not be your

                                                                                                                                                                                                                      1 OF 1
                                                                                                                                         Our organization processes the claims submitted                                           responsibility.
                                                                                                                                         from your health care provider(s). You have received
                                                    1 0.0104                                                                             this Explanation of Benefits (EOB) as our notification
                                                    TFATADATFADDFAAFTTTDFTDAFFTFADTAAADTFTDTTTDAAAATFATTDATTDDTFAADFT                    to you explaining how your claim(s), including                               ENV 1        Approved Amount – The amount Coventry agrees to pay
                                       1            Member, Jane D                                                                       payments or denials, are being processed.                                                 the provider for services rendered.
Eligibility Provisions
                                                    123 ANYWHERE ST.
                                                                                                                                              2
                                                    ANYWHERE, MO 64014
                                                                                                                                                         Payments made on behalf of:
                                                                                                                                                            Coventry Health Plan                                                   Other Carrier Allowed (Coordination of Benefits) – This
                                                                                                                                         Insured:       Member, John D
                                                                                                                                         Patient:       Member, Jane D                                                             field is not used by all health plans; if present, it is the dollar
                                                                                                                                         Group Name:
                                                                                                                                         ID Number:
                                                                                                                                                        XYZ Group
                                                                                                                                                        99XXXXXXX02
                                                                                                                                                                                                                                   amount your other health care insurance plan considered for
                                                                                                                                         Date:          10/19/2011                                                                 payment.
                                                                                                                                                                                                                                   Copay – Dollar amount member is responsible to pay.
Premium Billing                            3
                                       Your Health Is Important. Preventive care services include flu and pneumonia vaccines, mammograms, colorectal screenings and                                                                Coins. – Member’s shared expenses for eligible charges on
                                       spirometry (if you have COPD). Talk with your doctor to schedule needed services.
                                                                                                                                                                                                                                   a percentage basis. The member is responsible to pay this to
                                                                        **Payments made at the time services were rendered are not reflected on this statement.**
                                      Claim Number:                        8XXXXXX22                                                        Provider: CURE U FAMILY CARE PC
                                                                                                                                                                                                                                   the health care provider.
                                      Paid to Provider:                                                                    Provider Billing Address: 1 MEDICAL DR

Explanation of Benefits
                                                                           $0.00
                                      Paid to Member:                      $0.00                                                                      SOMEWHERE, MO 64014-
                                                                                                                                                                                                                                   Deduct. – Amount of eligible charges which the member
                                      Paid to Other:                       $0.00                  4                                                                                               5
                                      Total Plan Paid:                     $0.00                                                                                                                                                   must pay before benefits are payable. The member is
Statement (EOB)                       Member Responsibility:
                                      Service Date From - To
                                                                            $204.00
                                                                                       Billed Contractual
                                                                                                                  **Provider billing address may differ from physical office location**
                                                                                                                   Approved
                                                                                                                                    Patient Account #: 272727


                                                                                                                                    Member's Responsibility to Provider                   Plan        Cont./   Other
                                                                                                                                                                                                                                   responsible to pay this to the health care provider.
                                       Proc Code / Description                        Amount Adjustment             Amount          Copay     Coins   Deduct.        Other                Paid         Rmk      Rmk                Other – Descriptions of these codes are displayed in the
                              6       10/13/11-10/13/11
                                        99213 /OFFICE VISIT - F/U
                                                                                      $204.00          $0.00            $0.00            $0.00     $0.00       $0.00    $204.00           $0.00       0213     1595                “Other Remarks” section below this section.
                                                    TOTALS:                        $204.00          $0.00               $0.00            $0.00     $0.00        $0.00   $204.00           $0.00
                                                                                                                                                                                                                                   Other Carrier Paid (Coordination of Benefits) – This
Claims
                                      Coordination of Benefits:                 Other Carrier Allowed: $0.00                                Other Carrier Paid: $0.00
                                      Contractual Remarks:                                                                                                                                                                         field is not used by all health plans; if present, it is the dollar
                                        0213 - CHARGE EXCEEDS THE CONTRACTUAL ALLOWANCE PER THE CONTRACT
                              7                                                                                                                                                                                                    amount paid by your other health care insurance plan.
                                      Other Remarks:
                                       1595 - PATIENT HAS REFUSED TO ASSIGN BENEFITS
                                                                                                                                                                                                                                   Plan Paid – The amount paid by your plan.
                                      Grievance Review Process:


COBRA Continuation and
                                       PLEASE CONTACT A CUSTOMER SERVICE REPRESENTATIVE AT 1-866-611-7337 WITH ANY QUESTIONS OR CONCERNS.
                                      To ensure that your health plan was properly billed, please review the services listed on your explanation of benefits. If you believe any of the services were
                                                                                                                                                                                                                                   Cont. Rmk/Other Rmk – A Coventry Health Care code that
                              8       incorrectly billed, contact a customer service representative using the toll free number listed on your insurance card.
                                                                                                                                                                                                                                   defines the reason dollars were not paid by your health plan.
Medicare Coverages                    For diagnosis and treatment codes, the meanings of such codes, and questions regarding this notice, please call the number listed on your card.

                                      If you have a HRA/HSA/FSA with Coventry Consumer Choice (C3), or you have a medical plan with the Coventry Fund, you may be eligible for additional
                                      reimbursement on this claim. Check your fund or account on My Online Services at the website listed on your medical ID card for options.
                                                                                                                                                                                                                               7   Brief explanation of Cont. Rmk and/or Other Rmk
                                                                                                                                                                                                                                   codes, plus any optional detail text for the “Remarks” code.
                                                                                        The amounts below include claims processed as of 10/19/2011.
                                                                        The information does not reflect any claims received or adjusted after the above mentioned date.                                                       8   Other information and/or alerts from the plan.
                                                                           Member Medical Benefit Usage for Dates of Service January 01, 2011 - December 31, 2011


Wellness                                                                                                                                                                                                                           Member Medical Benefit Usage – if your plan has
                                                                                                      This may include deductible carry over dollars.
                              9                                                                                  Deductible Dollars                                         Out of Pocket Dollars
                                                                                                                                                                                                                               9
                                                                                             Year-To-Date            Maximum                  Remaining        Year-To-Date  Maximum                   Remaining
                                                                                                                                                                                                                                   deductibles and/or out-of-pocket maximums, the usage
                                                               Type                            Satisfied                 $                        $              Satisfied       $                         $                       table will display. This table is explained more fully on the
                                      OVERALL-Family                                       $     96.19             $  6,500.00              $ 6,403.81         $   96.19    $ 6,500.00                $ 6,403.81
                                                                                                                                                                                                                                   next page.
                                                                                                                                                                                                                                                                               CVTY.EOB.0112

Notices


Forms




  22                       www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Sample EOB Statement — Continued

Key Contact Information

Online Account
ManagementSM                          HOW TO READ YOUR MEMBER BENEFIT USAGE

Provider Search                 A   Benefits Header                        B   Benefit Period Header                 C    Benefit Accumulation
                                    • This introductory language               • This identifies the calendar             Summary
                                      precedes the Benefits                      year in which benefits are               • The information displayed
                                      Accumulation Summary.                      calculated.                                in the columns below is
My Online ServicesSM                • This date reflects                                                                    based upon your benefit
                                      when your claims                                                                      plan.
                                      were processed.

Benefits
                                                       A The amounts below include claims processed as of 10/19/11.

                                                The information does not reflect any claims received or adjusted after the above
                                                                                mentioned date.
Certificate of Coverage
                                                              B   Member Medical Benefit Usage for Dates of Service
                                                                      January 1, 2011 – December 31, 2011.
Contractual Agreements                                                     This may include deductible carry over dollars.

                                                                           Deductible Dollars                            Out-of-Pocket Dollars
Enrollment and
                                                              Year-to-Date      Maximum        Remaining      Year-to-Date      Maximum      Remaining
Termination Procedures                          Type
                                                               Satisfied           $              $            Satisfied           $            $
                                           OVERALL -
                                                                  $96.19         $6,500.00      $6,403.81        $96.19         $6,500.00     $6,403.81
                                           Family
Eligibility Provisions          C
                                                  1                  2                3              4              5               6              7




Premium Billing
                                1   Type—displays the benefit coverage level where dollars       5   Year-to-Date Satisfied—total amount spent or credited
                                    have been used or are tracked. If you have different             towards the maximum amount you are required to pay in
Explanation of Benefits             spending limits for different types of benefits, such as         the benefit year.
                                    in-network or out-of-network, they will be listed as
Statement (EOB)                     different types. For example, they may be listed as
                                                                                                 6   Maximum $—total amount you may be responsible for
                                                                                                     in a benefit year based on your benefit plan design.
                                    individual or family.
                                                                                                 7   Remaining $—total amount you have left to pay before
                                2   Year-to-Date Satisfied—total amount spent or credited
Claims                              towards the maximum amount you are required to pay
                                                                                                     the maximum limit is met (Maximum minus Year-to-Date
                                                                                                     Satisfied).
                                    before additional benefits are available.
                                3   Maximum $—total amount you must spend in the
COBRA Continuation and              benefit year before your additional insurance benefits
                                                                                                     If you have questions, call the
Medicare Coverages                  are available.                                                   customer service number printed
                                4   Remaining $—total amount you have left to pay on your            on your ID card.
                                    deductible before the maximum limit is met and your
                                    other insurance benefits apply (Maximum minus
Wellness                            Year-to-Date Satisfied).


                                                                                                                                              CVTY.EOB.0112


Notices


Forms




  23                       www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Claims

Key Contact Information   Occasionally, your employees may come to you with questions about their claims. They can find out if a claim has
                          been paid by checking My Online ServicesSM or by calling the toll-free customer service number on their ID card.
Online Account            Members may send us a question via secure email through My Online Services.
ManagementSM              For your reference, we have provided some helpful information below:
                          Claim status codes
Provider Search             • Approved — An approved claim that has either been — or will be — paid in full or at a determined partial
                              amount. Members can find detailed claim information available on My Online Services using the “View
                              Claims” option.
My Online ServicesSM
                            • Rejected — A rejected or denied claim. A claim may be rejected or denied for a number of reasons.
                              Members may refer to their explanation of benefits or call CHC Carolinas Customer Service for further
Benefits                      explanation.

                          For questions about a status other than those described, members may use the “ask a question about
Certificate of Coverage   this claim” functionality after clicking on the claim in question.


Contractual Agreements    Out-of-Area Services
                          If members are out of their service area and receive medical treatment, they must submit a claim form. They can
Enrollment and            find a claim form on My Online Services. In addition, members can send us an email or call Customer Service at
Termination Procedures    the number listed on the back of their ID card.

Eligibility Provisions    Preauthorization
                          Preauthorization, also known as prior authorization is required for some services. To avoid having claims denied,
Premium Billing           members should be sure to have providers contact the preauthorization department before receiving these
                          services. A list of these services can be found in the “Document Library” on the member portal of our website,
                          www.chccarolinas.com, or in the Group Contract Agreement.
Explanation of Benefits
Statement (EOB)
                          Complaint and Appeal Process
Claims                    If a member is unable to resolve a claim or other problem related to benefits or coverage, an appeal process is
                          available. Please refer to the Evidence of Coverage, Certificate of Insurance or plan document for a complete
                          description of the complaint and appeal process.
COBRA Continuation and
Medicare Coverages
                          Claims Address
Wellness                  Coventry Health Care of the Carolinas, Inc.
                          P.O. Box 7102
                          London, KY 40742
Notices


Forms




  24                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         COBRA Continuation and Medicare Coverages

Key Contact Information
                          COBRA Continuation of Coverage
                          When an employee’s coverage is terminated, your company is required to offer the terminated employee and
Online Account            applicable family dependents federally mandated continuation of group coverage (COBRA) and state-mandated
ManagementSM              continuation of group coverage. The attached Certificate of Coverage summarizes both of these coverage types
                          for your employees and their family dependents.
Provider Search
                          Important Notice!
My Online Services   SM
                          The following explanation of COBRA continuation of group coverage laws is provided as a courtesy to
                          you. As the employer, your company is responsible for complying with and administrating COBRA and
                          state continuation of group coverage. When an employee is hired, you are responsible for informing
Benefits                  the employee and family dependents of the availability to continue group coverage. In the event group
                          coverage is terminated, you are responsible for notifying the employee and family dependents of their
                          eligibility to continue group coverage.
Certificate of Coverage
                          Federally Mandated Coverage (COBRA)
Contractual Agreements    Under federal law, if you are an employer who has 20 or more employees, you are subject to the Consolidated
                          Omnibus Budget Reconciliation Act (COBRA). COBRA requires you to offer the option to continue your company’s
Enrollment and            current group health care benefit plan to members who have one of the following qualifying events:
Termination Procedures
                            • An employee who is terminated for any reason other than gross misconduct, who is laid off or whose hours are
                              reduced. Coverage may be continued for the employee and his or her family dependents for up to 18 months.
Eligibility Provisions
                            • A family dependent whose coverage ceases under the terms of the Group Agreement (“Plan”), or because of
                              divorce, legal separation, the subscriber’s death or the subscriber becoming eligible for Medicare, or if there
Premium Billing               is a loss of a child’s dependent status under the terms of the plan. Coverage for family dependents may be
                              continued for up to 36 months if there is a legal separation or if the subscriber has died, or for a dependent
                              child, if he or she ceases to meet the plan’s rules for dependent status.
Explanation of Benefits
Statement (EOB)           Coverage for the employee and his or her family dependents may be continued for 29 months if the Social
                          Security Administration determines that the employee was disabled at the time during the first 60 days of the
                          COBRA continuation coverage. The employee must notify the plan administrator of the determination within 60
Claims
                          days of the date of the determination and within the initial 18-month COBRA continuation period.

COBRA Continuation and      • In cases of Chapter 11 bankruptcy, a retiree and a beneficiary who loses coverage is substantially
Medicare Coverages            eliminated, within one year before or after the employer filed for bankruptcy. Retirees may continue
                              coverage until their death. The retiree’s family dependents may continue coverage until the earliest of either
                              the family dependent’s death or 36 months past the death of the retiree.
Wellness
                            • The employer must notify the COBRA administrator of a qualifying event within 30 days of when the
                              employer obtains knowledge of the event. These events include (1) the employee’s termination of
Notices                       employment (or reduction in hours); (2) the employee’s death; (3) the employee’s entitlement to Medicare;
                              or (4) the employee’s bankruptcy. If the employer is the COBRA administrator, the employer must send a
                              COBRA notice and election form to the employee and family dependents within 44 days of the event. The
Forms                         employee must notify the administrator of qualifying events that are not within the employer’s knowledge
                              within 60 days of the event. These events include (1) divorce or legal separation; or (2) a child’s loss of
                              student status. The plan administrator must give written notice to each individual who qualifies for continued
                              coverage within 14 days of the receipt of notice of a qualifying event.


  25                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Continuation and Medicare Coverages — Continued

Key Contact Information   The member has 60 days from either the date coverage is lost or, if it is later, the date he or she receives
                          notification from you to elect COBRA coverage. Even if the covered employee rejects COBRA, each family member
Online Account            has an independent right to elect continuation of coverage. You may require the member to pay the full cost of the
ManagementSM              COBRA coverage. Premiums may not exceed 102% of the premiums being paid by similarly situated employees.
                          Once a member is no longer eligible to receive COBRA coverage you must notify the member of the COBRA
                          termination.
Provider Search
                          Reminder: You are obligated to provide members with an initial COBRA notice upon plan enrollment.
                          When the coverage ends, this must be sent prior to the termination date.
My Online ServicesSM      It is important to note that the Internal Revenue Service may change or amend COBRA from time to time. Failure
                          to offer COBRA may result in fines and the loss of a business tax deduction for plan contributions.

Benefits
                          State-Mandated Coverage
                          Any state-mandated coverage applicable to your employee and their families is explained in the Group
Certificate of Coverage   Membership Agreement.


Contractual Agreements    Medicare
                          Medicare is the federal program that provides health insurance to the aged and disabled. Within the three
Enrollment and            months prior to an American citizen’s 65th birthday, the Social Security Office will send the individual information
Termination Procedures    concerning enrollment in Medicare.


Eligibility Provisions    Important Notice!
                          This explanation of Medicare is provided to you as a courtesy. As the employer, you are responsible for
                          complying with and administrating Medicare. We have provided an explanation of Medicare for your
Premium Billing
                          employees and their spouses in their Group Membership Agreements. For further information, contact
                          your local Social Security Office.
Explanation of Benefits
Statement (EOB)
                          Coordination of Benefits
Claims                    When a member is covered by another group health plan in addition to CHC Carolinas coverage, Coordination of
                          Benefits (COB) takes place. The COB provision is necessary to avoid duplication of benefits. To ensure that claims
                          are processed properly, information about other coverage of any member must be furnished to CHC Carolinas
COBRA Continuation and    promptly, and CHC Carolinas should be notified promptly of any coverage changes.
Medicare Coverages
                          When CHC Carolinas is the primary health plan, then CHC Carolinas pays first for all covered services; when
                          secondary, CHC Carolinas makes payment, according to provisions and benefit levels of this plan, after the
Wellness                  primary health plan has paid according to its contract. Even when CHC Carolinas is secondary, some medical
                          services require preauthorization. CHC Carolinas requires that members elect Medicare Part B when Medicare is
                          the primary payor.
Notices


Forms




  26                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Continuation and Medicare Coverages — Continued

Key Contact Information
                          Coordination of Benefits with Medicare for Members 65 and Over
Online Account
ManagementSM              When a member is covered by                                                          CHC Carolinas    Medicare
                                                                                       Then
                          Medicare and a group plan, and                                                        is Primary     is Primary
Provider Search           The member is age 65 or over, and           If the employer group has less than
                          is the subscriber or the subscriber’s       20 employees                                                 X
                          spouse, and the subscriber is actively
My Online ServicesSM      working for the employer group              If the employer group has 20 or
                                                                      more employees                                X

Benefits                  Is a person who becomes qualified for       If Medicare has been secondary to the
                          Medicare coverage due to ESRD after         group plan before ESRD entitlement,
                          already being enrolled in Medicare due      then for the first 30 months following        X
Certificate of Coverage   to age                                      ESRD entitlement

                                                                      If Medicare had been primary to the
                                                                      group plan before ESRD entitlement                           X
Contractual Agreements
                          The member is age 65 or over, is the
Enrollment and            subscriber or the subscriber’s spouse
Termination Procedures    and is not actively working for the group                                                                X


Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  27                        www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Wellness

Key Contact Information
                          Coventry WellBeingSM
                          Coventry WellBeing helps you make changes and improve your diet, fitness level, emotional well-being and more.
Online Account            Plus, you can find risk factors you may have for certain health conditions and get the information you need to
ManagementSM              make healthier choices.
                          With Coventry WellBeing, you can make meaningful lifestyle changes to improve your diet, fitness level, emotional
Provider Search           well-being and more. Plus, Coventry WellBeing can help you identify risk factors you may have for certain health
                          conditions and give you the information you need to make better choices for health.
My Online ServicesSM      Coventry WellBeing provides easy-to-use options that allow your employees to improve their own and their
                          family’s health through our complete, confidential wellness services. These include an online health risk
                          assessment, free online health improvement programs, health information and more.
Benefits                  Plus, Coventry WellBeing makes wellness fun. We encourage our members to participate by providing rewards
                          for doing so. All members who participate in the online Personal Health Improvement programs will earn points
                          toward valuable items or receive entries for prize drawings. Prizes include electronics, cash cards, fitness
Certificate of Coverage   equipment, spa packages and more. Continually interacting with the online program — including completing the
                          online health risk assessment (HRA) — earns even more points and more chances for prizes.
                            • Visit the web address shown on your ID card and login to My Online ServicesSM.
Contractual Agreements
                            • Under “Wellness Tools” select any of the links under WellBeing.
Enrollment and            Confidential Health Risk Assessment
Termination Procedures    You’ll probably want to know the state of your health before you start using the other wellness tools. The
                          confidential health risk assessment (HRA) is a questionnaire that asks questions about medical history, medical
Eligibility Provisions    conditions, and life habits. After you take the HRA, we give you a personal report that gives you a picture of your
                          state of health. We also give you suggestions for steps you can take to manage your health. You can reduce your
                          risks for developing health problems in the future while improving your life now.
Premium Billing

Explanation of Benefits   Mother to BeSM — Helping You Have a Healthy Baby
Statement (EOB)           Enroll in Mothers To Be online
                          During pregnancy, a woman’s body undergoes dramatic changes. It is a special time for both mother and baby.
Claims                    How you care for yourself when you are considering getting pregnant, such as taking folic acid every day, can
                          directly affect the well-being of you and your developing child.
COBRA Continuation and    If you are a CHC Carolinas member, our Mothers To Be program can provide you with assistance in answering
Medicare Coverages        questions you may have about your pregnancy and in communicating concerns you may have to your doctor.
                          What Is Mothers To Be?
Wellness                  Mothers To Be is a CHC Carolinas program developed to help pregnant women prepare for, deliver and care for a
                          healthy, full-term baby. The program is designed to support your participating obstetrician’s efforts by monitoring
Notices                   your progress and sharing helpful, professional information, and provides you with special care, education and
                          professional evaluations before, during and after your pregnancy.

Forms




  28                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Wellness — Continued

Key Contact Information   In addition, when you enroll in Mothers To Be, you’ll receive at no cost to you a variety of special services
                          including:
Online Account              • Support for high-risk mothers from a case manager throughout your pregnancy
ManagementSM
                            • Educational materials mailed directly to you

Provider Search           What does CHC Carolinas offer to all expectant mothers?
                          Expectant mothers enrolled in Coventry Select (HMO), Coventry Select Plus (POS), and Open Access plans, are
                          eligible for a variety of prenatal services from CHC Carolinas, in addition to the Mothers To Be program.
My Online ServicesSM
                          As examples, expectant mothers are encouraged to attend childbirth education classes at CHC Carolinas
                          participating facilities, and will be reimbursed for their registration fee. CHC Carolinas also encourages all
                          pregnant women to stop smoking, and provides benefits under some plans that cover smoking cessation drugs
Benefits
                          or programs.
                          For more information or to check benefit plans for smoking cessation, email CHC Carolinas Member Services, or
Certificate of Coverage   call 800-935-7284 from 8 a.m. to 6 p.m., Monday through Friday, except holidays.
                          Enroll in Mothers To Be today!
Contractual Agreements    CHC Carolinas members can enroll in our Mothers To Be program by emailing us or by calling toll-free at
                          800-708-9355, extension 1721.
Enrollment and
Termination Procedures    Tobacco Cessation
                          Members Can Earn Money When They Quit Smoking
Eligibility Provisions
                          Members who successfully stop smoking while covered by CHC Carolinas can earn up to $165*. After quitting, all
                          they need to do is provide the following to CHC Carolinas:
Premium Billing             • Receipts for the prescription or over-the-counter drugs, or non-pharmaceutical smoking cessation program,
                              and
Explanation of Benefits     • A signed written statement affirming that they have stopped using tobacco products, including cigarettes,
Statement (EOB)               cigars, pipes and smokeless tobacco
                            • Send above to the claims address on your member ID card
Claims
                          Help is available
                          The North Carolina Tobacco Use Quit Line is available to all North Carolinians—youth and adults. They offer
COBRA Continuation and    confidential assistance between 8 a.m. and midnight, seven days a week. The Quit Line is available in multiple
Medicare Coverages        languages. Quit Coaches can call tobacco users back upon request or make the first call.
                          Members can talk to a Quit Coach who will offer:
Wellness
                            •   Support
                            •   Materials for quitting
Notices                     •   Referral to local resources
                            •   Medication information
Forms                       •   Help making a plan
                            •   Assistance in setting a quit date
                            •   Follow-up calls




  29                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Wellness — Continued

Key Contact Information   800-QUIT-NOW (800-784-8669)
                          Fax referral available if physician would like the Quitline to make the first call to patients.
Online Account            Fax is 800-483-3114. A referral form can be downloaded from www.quitlinenc.com.
ManagementSM
                          To learn more about the smoking cessation reimbursement program, contact your CHC Carolinas
                          representative.
Provider Search
                          * From the Group Certificate of Coverage Regarding Reimbursement: The maximum allowable amount covered by the plan for the actual costs for
                          prescription or over-the-counter drugs, or non-pharmaceutical smoking cessation programs. The maximum allowable amount Covered by the Plan is
                          $165.00 per Covered Person per lifetime.
My Online ServicesSM

                          Diabetes FAQ
Benefits
                          Frequently Asked Questions Regarding Plan Benefits for Members Diagnosed
                          with Diabetes
Certificate of Coverage
                          How do I enroll in the CHC Carolinas Diabetes Management Program?
                          Members interested in joining the CHC Carolinas Diabetes Management program may call 800-708-9355 ext.
Contractual Agreements    1721. The program’s focus is to increase member’s awareness of their condition and the value of its treatment
                          and self-management.
Enrollment and            How are glucose monitoring strips covered under the benefit plan?
Termination Procedures    Glucose monitoring strips and lancets are covered under the pharmacy rider and the copayment amount will
                          depend upon the brand that the member uses. LifeScan is the brand that is on the Formulary and the member
Eligibility Provisions    responsibility is the 2nd tier copayment. All other brands not on the formulary require prior authorization
                          including: Abbott Freestyle Systems, Bayer Ascensia Contour Systems, MediSense Precision Systems, Roche
                          Accu-Chek Systems, TrueTrack Systems and other non-LifeScan meter systems. If approved the member
Premium Billing           will be responsible for a 3rd tier copayment. Please note, the precertification department would need to find
                          documentation in your medical records that indicates why the LifeScan strips will not work for you. It is strongly
                          urged that you switch to the LifeScan strips unless there is a real need.
Explanation of Benefits
Statement (EOB)           How are Glucometers covered under the benefit plan? How do I obtain a Glucometer?
                          As a benefit to our members with diabetes, CHC Carolinas offers a Free LifeScan Glucometer (one time only)
Claims                    to all members who are diagnosed with Diabetes. A free LifeScan Glucometer can be obtained by asking your
                          physician to fax a prescription for the above brand to 704-357-6659 or by contacting the Customer Service
                          Organization at 800-935-7284.
COBRA Continuation and
Medicare Coverages        The following LifeScan meters are covered:
                             • ONETOUCH® UltraMini System
                             • ONETOUCH® Ultra2 System
Wellness
                             • ONETOUCH® UltraSmart System

Notices                   A member can get more specific information on each meter by calling LifeScan at 800-227-8862, and speaking
                          with a specialist or by visiting their website at www.lifescan.com.

                          How are medications such as insulin and oral diabetic agents covered?
Forms
                          Insulin is covered under your pharmacy rider. The member copayment will depend upon the brand used. The
                          following brands are on the Formulary and the member responsibility is a 2nd tier copayment: Iletin, Humulin,
                          Humalog and Lantus. Novolin, Levemir and Apidra are not on the Formulary and require a 3rd tier copayment.



  30                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Wellness — Continued

Key Contact Information   The following brand name oral diabetic agents are on the formulary and require a 2nd tier copayment: Dymelor,
                          Diabinese, Orinase, Tolinase, Diabeta, Glynase, Micronase, Glucuotrol-XL, Amaryl, Glucophage, Glucophage XR,
Online Account            Actos, Avandia, Avandamet and Precose. Many of these have a generic substitution available that would require
ManagementSM              a 1st tier copayment. [If the prescription is changed to the generic equivalent, the member copayment would be
                          lower (1st tier). If the prescription is not changed, the copayment will be increased by an “ancillary charge” and
                          may be higher than the usual 2nd tier copayment.]
Provider Search
                          Prior authorization is required for the following diabetes medications: Actos, Avandia, Avandamet, Actoplus Met,
                          Avandaryl, Byetta, Symlin, Janumet, Januvia and Duetact. To obtain prior authorization the physician should call
My Online ServicesSM      877-215-4100.
                          Insulin in vials does not require any precertification. However, Insulin Pens and cartridges do require
                          precertification with the exception of short acting insulins (such as, Humalog and Novolog). To obtain prior
Benefits                  authorization the physician should call 877-215-4100.
                          What if I need an insulin pump?
Certificate of Coverage   Insulin pumps do require precertification — have your physician call CHC Carolinas Health Services to precertify
                          at 866-935-7284. (The insulin pump and supplies are covered under the Durable Medical Equipment portion
                          of the medical policy.)
Contractual Agreements
                          The drugs listed above and whether or not they are on the formulary may change frequently. If you have
                          any questions, call the CHC Carolinas Customer Service Department at 800-935-7284.
Enrollment and
Termination Procedures
                          Vision Care
Eligibility Provisions    Focused on Vision Wellness
                          Regular eye exams not only help correct vision problems; comprehensive eye exams can also reveal the warning
                          signs of more serious undiagnosed health problems such as hypertension, cardiovascular disease and diabetes.
Premium Billing           No matter what the age, eye exams are important to health.
                          As we age our eyes are also at greater risk for sight-threatening conditions such as cataracts and macular
Explanation of Benefits   degeneration. Annual comprehensive eye exams canhelp detect these conditions and many others before
Statement (EOB)           damage is irreversible. CHC Carolinas members receive an eye exam for only $50.
                          Your Vision Care Discount
Claims                    CHC Carolinas members now have new options to save on eyewear through a materials discount program
                          offered by EyeMed Vision Care®. This program is available to all members and eligible dependents and cannot be
COBRA Continuation and    combined with any other discounts.
Medicare Coverages
                          Choice and Convenience
                          The EyeMed SELECT network offers you the choice of leading optical retailers including LensCrafters, Pearle
Wellness                  Vision, Sears Optical, Target Optical, JCPenney Optical, as well as thousands of private practitioners, all near
                          where you work and shop.
Notices                   Accessing Your Vision Care Discount
                          EyeMed makes it as easy as 1-2-3 to protect your vision.
Forms                     1. Locate a provider by visiting www.eyemedvisioncare.com. On the homepage, you can select the Locate
                             a Provider feature and choose the SELECT network to view your providers. You can also locate providers and
                             review your discount by clicking on the “Members” tab, “Log-In/Register,” then click on the letter “C”. Once
                             there you can choose your plan and then select the option to locate a provider.



  31                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Wellness — Continued

Key Contact Information   2. Schedule an appointment with a simple phone call. Or stop by one of the many providers who offer walk-in
                             appointments. Inform the office that you are a CHC Carolinas member with an EyeMed discount plan when you
Online Account               wish to use your discount.
ManagementSM              3. Present your CHC Carolinas ID Card when you arrive so the EyeMed provider knows you have a CHC
                             Carolinas vision discount.
Provider Search           Please note your discount cannot be combined with any other discounts, coupons or promotional offers.

My Online ServicesSM


Benefits
                                           If you have questions or need further assistance, please visit
Certificate of Coverage                         our website at www.chccarolinas.com or contact
                                                           your account representative.
Contractual Agreements

Enrollment and
Termination Procedures

Eligibility Provisions


Premium Billing

Explanation of Benefits
Statement (EOB)

Claims

COBRA Continuation and
Medicare Coverages

Wellness


Notices


Forms




  32                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Notices

Key Contact Information
                          Your Privacy Matters
Online Account            In compliance with the Health Insurance Portability and Accountability Act (HIPAA), Coventry Health Care, Inc.,
ManagementSM              and each member of the Coventry Health Care family of companies (an “Affiliate”)i, is sending you important
                          information about how your medical and personal information may be used and about how you can access this
                          information. Please review the Notice of Privacy Practices carefully. If you have any questions, please call the
Provider Search           Member Services number on the back of your membership identification card.

                          Notice of Privacy Practices
My Online ServicesSM
                          Effective: 4/14/2003 (Revised 7/27/2012)
                          THIS NOTICE DESCRIBES HOW MEDICAL AND PERSONAL INFORMATION ABOUT YOU MAY BE USED AND
Benefits                  DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
                          A. Our Commitment to Your Privacy
Certificate of Coverage   We understand the importance of keeping your personal and health informationii secure and private. We are
                          required by law to provide you with this notice. This notice informs you of your rights about the privacy of your
                          personal information and how we may use and share your personal information. We will make sure that your
Contractual Agreements    personal information is only used and shared in the manner described. We may, at times, update this notice.
                          Changes to this notice will apply to the information that we already have about you as well as any information
Enrollment and            that we may receive or create in the future. Our current notice is posted at www.cvty.com. You may request a
Termination Procedures    copy at any time. Throughout this notice, examples are provided. Please note that all of these examples may not
                          apply to the services we provide to your particular health benefit plan.

Eligibility Provisions    B. What Types of Personal Information Do We Collect?
                          To best service your benefits, we need information about you. This information may come from you, your
                          employer, or other payors or health benefits plan sponsors, and our Affiliates. Examples include your name,
Premium Billing           address, phone number, and Social Security number, date of birth, marital status, employment information,
                          or medical history. We also receive information from health care providers and others about you. Examples
Explanation of Benefits   include the health care services you receive. This information may be in the form of health care claims and
Statement (EOB)           encounters, medical information, or a service request. We may receive your information in writing, by telephone,
                          or electronically.
Claims                    C. How Do We Protect the Privacy of Your Personal Information?
                          Keeping your information safe is one of our most important duties. We limit access to your personal information
COBRA Continuation and    to those who need it. We maintain appropriate safeguards to protect it. For example, we protect access to our
Medicare Coverages        buildings and computer systems. Our Privacy Office also assures the training of our staff on our privacy and
                          security policies.
Wellness                  D. How Do We Use and Share Your Information for Treatment, Payment, and Health
                          Care Operations?
Notices                   To properly service your benefits, we may use and share your personal information for “treatment,” “payment,”
                          and “health care operations.” Below we provide examples of each. We may limit the amount of information we
                          share about you as required by law. For example, HIV/AIDS, substance abuse, and genetic information may be
Forms                     further protected by law. Our privacy policies will always reflect the most protective laws that apply.
                            T
                          •		 reatment:	We may use and share your personal information with health care providers for coordination and
                            management of your care. Providers include physicians, hospitals, and other caregivers who provide services
                            to you.


  33                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Notices — Continued

Key Contact Information     P
                          •		 ayment:	We may use and share your personal information to determine your eligibility, coordinate care,
                            review medical necessity, pay claims, obtain external review, and respond to complaints. For example, we may
Online Account              use information from your health care provider to help process your claims. We may also use and share your
ManagementSM                personal information to obtain payment from others that may be responsible for such costs.
                            H
                          •		 ealth	care	operations: We may use and share your personal information as part of our operations
Provider Search             in servicing your benefits. Operations include credentialing of providers; quality improvement activities;
                            accreditation by independent organizations; responses to your questions, or grievance or external review
                            programs; and disease management, case management, and care coordination. We may also use and share
My Online ServicesSM        information for our general administrative activities such as pharmacy benefits administration; detection and
                            investigation of fraud; auditing; underwriting and rate-making; securing and servicing reinsurance policies; or
                            in the sale, transfer, or merger of all or a part of a Coventry company with another entity. For example, we may
Benefits                    use or share your personal information in order to evaluate the quality of health care delivered, to remind you
                            about preventive care, or to inform you about a disease management program.
                          We may also share your personal information with providers and other health plans for their treatment, payment,
Certificate of Coverage   and certain health care operation purposes. For example, we may share personal information with other health plans
                          identified by you or your plan sponsor when those plans may be responsible to pay for certain health care benefits.

Contractual Agreements    E. What Other Ways Do We Use or Share Your Information?
                          We may also use or share your personal information for the following:
Enrollment and              M
                          •		 edical	home/accountable	care	organizations:	We may work with your primary care physician, hospitals
Termination Procedures      and other health care providers to help coordinate your treatment and care. Your information may be shared
                            with your health care providers to assist in a team-based approach to your health.
Eligibility Provisions      H
                          •		 ealth	care	oversight	and	law	enforcement:	To comply with federal or state oversight agencies. These
                            may include, but are not limited to, your state department of insurance or the U.S. Department of Labor.
                          •	Legal	proceedings: To comply with a court order or other lawful process.
Premium Billing
                          •	Treatment	options: To inform you about treatment options or health-related benefits or services.
Explanation of Benefits     P
                          •		 lan	sponsors:	To permit the sponsor of your health benefit plan to service the benefit plan and your benefits.
Statement (EOB)             Please see your employer’s plan documents for more information.
                            R
                          •		 esearch:	To researchers so long as all procedures required by law have been taken to protect the privacy of
Claims                      the data.
                            O
                          •		 thers	involved	in	your	health	care: We may share certain personal information with a relative, such as your
                            spouse, close personal friend, or others you have identified as being involved in your care or payment for that
COBRA Continuation and
                            care. For example, to those individuals with knowledge of a specific claim, we may confirm certain information
Medicare Coverages
                            about it. Also, we may mail an explanation of benefits to the subscriber. Your family may also have access to such
                            information on our Web site. If you do not want this information to be shared, please tell us in writing.
Wellness                    P
                          •		 ersonal	representatives: We may share personal information with those having a relationship that gives
                            them the right to act on your behalf. Examples include parents of an unemancipated minor or those having a
                            Power of Attorney.
Notices
                            B
                          •		 usiness	associates:	To persons providing services to us and who assure us that they will protect the
                            information. Examples may include those companies providing your pharmacy or behavioral health benefits.
Forms                       O
                          •		 ther	situations:	We also may share personal information in certain public interest situations. Examples include
                            protecting victims of abuse or neglect; preventing a serious threat to health or safety; tracking diseases or medical
                            devices; or informing military or veteran authorities if you are an armed forces member. We may also share your
                            information with coroners; for workers’ compensation; for national security; and as required by law.


  34                         www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
Table of Contents         Notices — Continued

Key Contact Information
                          F. What About Other Sharing of Information and What Happens If You Are No
Online Account
                          Longer Enrolled?
ManagementSM              We will obtain your written permission to use or share your health information for reasons not identified by this
                          notice and not otherwise permitted or required by law. If you withdraw your permission, we will no longer use or
                          share your health information for those reasons.
Provider Search
                          We do not destroy your information when your coverage ends. It is necessary to use and share your information,
                          for many of the purposes described above, even after your coverage ends. However, we will continue to protect
My Online ServicesSM      your information regardless of your coverage status.
                          G. Rights Established by Law
Benefits                    R
                          •		 equesting	restrictions:	You can request a restriction on the use or sharing of your health information for
                            treatment, payment, or health care operations. However, we may not agree to a requested restriction.
                            C
                          •		 onfidential	communications:	You can request that we communicate with you about your health and
Certificate of Coverage     related issues in a certain way, or at a certain location. For example, you may ask that we contact you by mail,
                            rather than by telephone, or at work, rather than at home. We will accommodate reasonable requests.
                            A
                          •		 ccess	and	copies:	You can inspect and obtain a copy of certain health information. We may charge a fee for
Contractual Agreements
                            the costs of copying, mailing, labor, and supplies related to your request. We may deny your request to inspect
                            or copy in some situations. In some cases denials allow for a review of our decision. We will notify you of any
Enrollment and              costs pertaining to these requests, and you may withdraw your request before you incur any costs. You may
Termination Procedures      also request your health information electronically and it will be provided to you in a secure format.
                            A
                          •		 mendment:	You may ask us to amend your health information if you believe it is incorrect or incomplete.
Eligibility Provisions      You must provide us with a reason that supports your request. We may deny your request if the information is
                            accurate, or as otherwise allowed by law. You may send a statement of disagreement.
                            A
                          •		 ccounting	of	disclosures:	You may request a report of certain times we have shared your information.
Premium Billing             Examples include sharing your information in response to court orders or with government agencies that
                            license us. All requests for an accounting of disclosures must state a time period that may not include a date
Explanation of Benefits     earlier than six years prior to the date of the request and may not include dates before April 14, 2003. We will
Statement (EOB)             notify you of any costs pertaining to these requests, and you may withdraw your request before you incur any
                            costs.
Claims                    H. To Receive More Information or File a Complaint
                          Please contact Member Services to find out how to exercise any of your rights listed in this notice, or if you have
COBRA Continuation and    any questions about this notice. The telephone number or address is listed in your benefit documents or on your
Medicare Coverages        membership card. If you believe we have not followed the terms of this notice, you may file a complaint with us
                          or with the Secretary of the Department of Health and Human Services. To file a complaint with the Secretary,
                          write to 200 Independence Avenue, S.W. Washington, D.C. 20201 or call 1-877-696-6775. You will not be
Wellness                  penalized for filing a complaint. To contact us, please follow the complaint, grievance, or appeal process in your
                          benefit documents.
Notices

                                 i
                                   For purposes of this notice, the pronouns “we”, “us” and “our” and the name “Coventry” refers to Coventry Health Care, Inc. and its licensed
Forms                     affiliated companies.
                               ii
                                  Under various laws, different requirements can apply to different types of information. Therefore, we use the term “health information” to mean
                          information concerning the provision of, or payment for, health care that is individually identifiable. We use the term “personal information” to include both
                          health information and other nonpublic identifiable information that we obtain in providing benefits to you.




  35                          www.chccarolinas.com | NC Customer Service 800-935-7284 | SC Customer Service 888-935-7284
                                                               Enrollment/Change Form
                                                                           1-25 Employees
         *Denotes required fields for enrollment. For items with ** please select a Reason for Enrollment OR a Reason for Change.
 A    EMPLOYER INFORMATION: To Be Completed By Employer
 ☐    New Group                   ☐    New Enrollment                     ☐    Change                  ☐    Waive
 Company Name:                                                                          *Group No.:


 *Date Employed Full Time:                                                              *Effective Date of Coverage or Change


          Pre-existing conditions exclusion period is 12 months unless you provide proof of coverage (Certificate of Creditable Coverage) from your prior plan(s).
                      **REASON FOR ENROLLMENT                                                                       **REASON FOR CHANGE:
                                                                                                     (Please check all that apply and include supporting documentation.)

      New Group                                   New Hire                                   Enroll Dependent                          Terminate Dependent
      COBRA                                       Retired                                    Terminate Subscriber                      Name Change (Previous Name)
      Open Enrollment                             Qualifying Event (Reason)                  Address/Phone                             _____________________________
                                            Date:                                       Termination Reason:
                                            __________________________                       Group Request                 Member Request                      Deceased
 EMPLOYEE STATUS:
 ☐ Active         ☐ COBRA            ☐ Salary         ☐ Hourly / Number of hours a week _____                    ☐ Other ___________________________________
 B    SUBSCRIBER INFORMATION
 I ELECT THE FOLLOWING PLAN FOR MYSELF AND MY DEPENDENTS: ☐ None/Waive (please complete Section F and G)
 ☐ Coventry Health Care of the Carolinas, Inc. POS ___ ☐ Coventry Health Care of the Carolinas, Inc. HMO ___ ☐ Other __________________
 Type of Coverage:    ☐ Employee ☐ Employee/Spouse ☐ Employee/Children ☐ Employee/Spouse/Children
 *Last Name                                                                              *First Name                                                                MI


 *Gender                                     *Birthdate                                                     *Social Security Number
 ☐ Male ☐ Female
 *Address


 *City                                                                                      *State                 *ZIP Code


 Email address                                                                              *Height                                      *Weight


 Marital Status (please check one.)               ☐ Single/Widowed             ☐ Married          ☐ Divorced           ☐ Separated
 Work Phone                                 Home Phone                                  Primary Care Provider
                                                                                        PCP #:                                   PCP Name:
 C    FAMILY MEMBERS TO BE COVERED OR DELETED
 If address and phone numbers of covered dependents are different from that of policy holder, please attach that information on a separate sheet of paper.

      Add              *Last Name                                                        *First Name                                                                MI
      Delete
 *Gender               *Relationship           Disabled              *Birthdate                                *Social Security Number
      Male                   Spouse                 Disabled
      Female                 Child                                   *Height                      Weight                      Primary Care Provider
                             Other __________________                                                                         PCP #
                                                                                                                              PCP Name:
      Add              *Last Name                                                        *First Name                                                                MI
      Delete
 *Gender               *Relationship           Disabled              *Birthdate                                *Social Security Number
      Male                   Spouse                 Disabled
      Female                 Child                                   *Height                      *Weight                     Primary Care Provider
                             Other __________________                                                                         PCP #
                                                                                                                              PCP Name:
NC SM GRP 1-25 09-11                                                                                           Coventry Health Care of the Carolinas, Inc. (CHC Carolinas)   1 of 4
*Applicant Name: ________________________________________ (required)
       Add          *Last Name                                              *First Name                                                     MI
       Delete
 *Gender            *Relationship          Disabled         *Birthdate                         *Social Security Number
       Male                 Spouse             Disabled
       Female               Child                           *Height                *Weight                 Primary Care Provider
                            Other __________________                                                       PCP #
                                                                                                           PCP Name:
       Add          *Last Name                                              *First Name                                                     MI
       Delete
 *Gender            *Relationship          Disabled         *Birthdate                         *Social Security Number
       Male                 Spouse             Disabled
       Female               Child                           *Height                *Weight                 Primary Care Provider
                            Other __________________                                                       PCP #
                                                                                                           PCP Name:
 D     PRIOR HEALTH INSURANCE INFORMATION AND OTHER MEDICAL AND/OR PHARMACY COVERAGE INFORMATION
 D1 PRIOR HEALTH INSURANCE
  This section MUST be completed to receive credit for prior coverage and REDUCE or ELIMINATE any applicable waiting period.
     Have you had any health insurance within the last sixty-three (63) days?
         Yes           No            If YES, complete below and provide certificate of coverage:
 Name, Address, and Phone Number of Health Insurance Company


 Policy Number                          Policyholder Name                                    Policyholder Date of Birth (mmddyy)


 Effective Date (mmddyy)                      Termination Date or Expected Termination Date (mmddyy)             If other coverage will remain in
                                                                                                                effect, write N/A in term box, and
                                                                                                                 complete section below.
 Family Members Covered               List Names and Relationships:


 Have you or any family dependents been a previous Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) Plan           ☐ Yes ☐ No
 member?
 If YES, then dates and ID numbers:
                                          NOTICE ABOUT YOUR PRE-EXISTING CONDITION LIMITATIONS
 This plan imposes a pre-existing condition exclusion for all employees and dependents whether they are timely or late enrollees. This means that if
 you have a medical condition before coming to our plan, you may have to wait a certain period of time before the plan will provide coverage for that
 condition. This exclusion applies only to conditions for which medical advice, diagnosis care or treatment was recommended or received within a
 six-month period. Generally, this six month period ends on the day before your coverage becomes effective. However, if you were in a waiting period
 for coverage, the six-month period ends on the day before the waiting period begins. The pre-existing condition exclusion does not apply to children
 under 19 years old, to pregnancy, nor to a child who is enrolled in the plan within 31 days of birth, adoption or placement for adoption or foster care.
 Eligible children (newborns, adoptive children, foster children and those added as a result of a court order) are not subject to this exclusion period
 when enrolled more than 31 days after one of the events listed above if your coverage type or the premiums owed are not affected by adding the child.
 When applicable, this exclusion may last up to 12 months from your first day of coverage, or, if you were in a waiting period, from the first day of your
 waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior "creditable coverage."
 Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break
 in coverage of at least 63 days. To reduce the 12 month exclusion period by your creditable coverage, you should give Coventry Health Care of the
 Carolinas, Inc. (CHC Carolinas) a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior
 health coverage, Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) will help you obtain one from your prior plan or issuer. There are also
 other ways that you can show you have creditable coverage. Please contact Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) if you need
 help demonstrating creditable coverage. Throughout this notice, all references to “you” are meant to refer to both the employee and their dependents.
 D2    When coverage with CHC Carolinas begins, will you or any of your family members have any other medical insurance                       Yes
       coverage? If you answered yes, please complete below.                                                                                  No
 COVERAGE TYPE:             ☐ Group Policy ☐ Individual Policy ☐ Medicare ☐ Pharmacy ☐ Medicaid ☐ Tricare ☐ Other __________________
 Other Insurance Company Name                     Policy Holder Name                         Covered Dependents


 Relationship                        Gender           Birthdate                                    Effective Date of Other Insurance
      Spouse           Child            Male
      Other _______________             Female

NC SM GRP 1-25 09-11                                                                                                                                  2 of 4
*Applicant Name: ________________________________________ (required)
 E    HEALTH INFORMATION
 (Please answer each question fully and accurately. Incomplete answers could delay the processing of your requested coverage.)
 It is further understood that CHC Carolinas reserves the right to re-rate coverage if any supplied information is materially inaccurate or incomplete. Coverage
 may be rescinded in the event of fraud or intentional material misrepresentation. Please provide the health history of you and your family members who will
 be covered on this application. For all "yes" answers, please CIRCLE the condition and provide details in the appropriate section below. Conditions include
 but are not limited to the following:
 1    Cancer, tumor, or cyst                                                                                                          ☐ YES           ☐ NO
 2    Epilepsy, stroke, or paralysis                                                                                                  ☐ YES           ☐ NO
 3    Head or spinal injuries, Muscular Dystrophy, Cerebral Palsy, or Multiple Sclerosis                                              ☐ YES           ☐ NO
 4    Neck or back pain, disorders of the spine, or disk herniation/bulge                                                             ☐ YES           ☐ NO
 5    Any blood disorder (such as anemia, sickle cell, or hemophilia)                                                                 ☐ YES           ☐ NO
 6    Bladder, kidney (kidney failure or dialysis), prostate, testicular, uterine, or breast conditions                               ☐ YES           ☐ NO
 7    Vascular (blood vessel) disease                                                                                                 ☐ YES           ☐ NO
 8    Ulcerative colitis, Crohn's, diverticulitis, stomach ulcers, acid reflux, hernia, gallbladder, or rectal disorders              ☐ YES           ☐ NO
 9    Asthma, allergies, or hay fever                                                                                                 ☐ YES           ☐ NO
 10   Emphysema, Chronic Obstructive Pulmonary Disease, Cystic Fibrosis, or any other lung/respiratory disorder                       ☐ YES           ☐ NO
 11   Diabetes: Type 1 or II (Please give full details below)                                                                         ☐ YES           ☐ NO
 12   High Blood Pressure                                                                                                             ☐ YES           ☐ NO
 13   Heart disease, irregular heartbeat, heart murmur, chest pain, or heart valve conditions                                         ☐ YES           ☐ NO
 14   Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS)                                                ☐ YES           ☐ NO
 15   Cigarette or tobacco use  If yes, type or product and how much per day ______________________________                          ☐ YES           ☐ NO
 16   Thyroid, pituitary, pancreas, glandular, or disorder requiring growth hormones                                                  ☐ YES           ☐ NO
 17   Mental or nervous problems                                                                                                      ☐ YES           ☐ NO
 18   Disease of the eyes, ears, nose, sinuses, or throat (except glasses)                                                            ☐ YES           ☐ NO
 19   Arthritis, joint pain, lupus, fibromyalgia, fractures, or limb loss                                                             ☐ YES           ☐ NO
 20   Hepatitis  Type: A | B | C | D (Please circle) OR any other liver disorder/disease _______________________                     ☐ YES           ☐ NO
 21   Any drug or alcohol problems                                                                                                    ☐ YES           ☐ NO
 22   Treatment or rehab for drug or alcohol problems  When ____/ _______ (Month/Year)                                               ☐ YES           ☐ NO
 23   Any organ transplant (planned, recommended, or already performed)                                                               ☐ YES           ☐ NO
 24   Is anyone to be covered currently pregnant  Due date ____/____/_______ (Month/Day/Year)                                        ☐ YES           ☐ NO
 25   Any hospitalizations in the last 5 years (Please give full details below)                                                       ☐ YES           ☐ NO
 26   Any future surgeries discussed, planned, or recommended (Please give full details below)                                        ☐ YES           ☐ NO
 27   Currently taking any prescription medications (Please give full details below)                                                  ☐ YES           ☐ NO
 28   Are there any other medical conditions not listed above (Please give full details below)                                        ☐ YES           ☐ NO
                  Please give full details for all "Yes" questions above. Additional pages may be used but must be signed and dated.
                                                                                                   Medications (oral,
                                                                             Treatment                                     Is further treatment needed? If yes,
 Question Number           Person's Name                Condition                               injectable, infusion, or
                                                                            (Month/Year)                                               please explain
                                                                                                       inhaled)




NC SM GRP 1-25 09-11                                                                                                                                        3 of 4
*Applicant Name: ________________________________________ (required)
 Medicare Information
 ☐ Subscriber or ☐ Dependent                                    Dependent's Last Name                                         Reason for Medicare Eligibility

                                                                                                                              ☐ Over 65
                    Effective Date Of:                          Dependent's First Name                                 MI     ☐ Disabled
 Part A                                                                                                                       ☐ Kidney Disease (ESRD)
 Part B                                                         Medicare #                                                    ☐ ALS (Lou Gehrig's Disease)
 Part D
 ☐ Subscriber or ☐ Dependent                                    Dependent's Last Name                                         Reason for Medicare Eligibility

                                                                                                                              ☐ Over 65
                    Effective Date Of:                          Dependent's First Name                                 MI     ☐ Disabled
 Part A                                                                                                                       ☐ Kidney Disease (ESRD)
 Part B                                                         Medicare #                                                    ☐ ALS (Lou Gehrig's Disease)
 Part D
 F    WAIVER        My employer has given me an opportunity to apply for group health coverage for myself and my dependents (if applicable)

 I have declined to apply for coverage for  ☐ myself, ☐ spouse, ☐ dependents
 Reason for decline:     ☐ Other health insurance ☐ Spousal coverage ☐ Other reason (please explain)
 _____________________________________________________________________________________________________________________
 I understand that if I decide to apply for health coverage for myself and any applicable dependents at a later date, neither my dependents nor I will
 be eligible for coverage until (1) my employer’s next open enrollment period, or (2) there is a qualifying event as defined in the EOC.

 ____________________________________________________________________________                                  ___________________________________
 Employee Signature (only if you are waiving coverage)                                                         Date:
 G    CONDITIONS OF ENROLLMENT                             Please read the following carefully.
 I hereby apply for membership or request a change in membership in this Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) Plan. I understand that
 my enrollment and benefits are in accordance with those described in the applicable Evidence/Certificate of Coverage and Group Contract. I authorize 1) all
 health providers and insurers to furnish CHC Carolinas, and 2) all health providers and CHC Carolinas to furnish all insurers and health providers records con-
 cerning me or any member of my family for whom information is requested for any purpose required for the coverage of benefits including, but not limited to, the
 coordination of payments with other insurers or in connection with the provision of medical care. I understand that I or my authorized representative is entitled
 to receive a copy of this form containing this authorization for disclosure of information. A photographic copy of this authorization shall be valid as the original.
 I authorize my employer to deduct from my wages the amount required (if any) to cover my contribution for coverage. I certify that all the above information is
 correct. For claim adjudication purposes, this authorization is valid for the duration of my coverage for health benefits through CHC Carolinas. For purposes of
 collecting information for an insurance policy application, policy reinstatement, or a request for change in policy benefits, this authorization shall remain valid
 for thirty months from the date the authorization is signed. It is further understood that CHC Carolinas reserves the right to re-rate coverage if any supplied
 information is materially inaccurate or incomplete, or rescind coverage in the event of fraud or intentional material misrepresentation.
 AGREEMENT AND AUTHORIZATION
 By signing this form, I agree on behalf of myself and those family members enrolled in this CHC Carolinas Plan (Dependents) for whom I have authority to enroll
 and to consent on their behalf (collectively my Dependents and I shall be referred to as Enrolled Family) that CHC Carolinas may use or disclose to third parties
 the information contained on this enrollment form and individually identifiable health information relating to my Enrolled Family for purposes of administering
 my health insurance benefit including treatment, payment, or health care operations, as those terms are explained in detail in CHC Carolinas' Notice of Privacy
 Practices and to the extent permitted by law. My Enrolled Family’s consent includes agreement for the use or disclosure of health information that may include
 diagnosis, prognosis, treatment, and payment information related to physical and/or mental illness, including substance abuse, Acquired Immune Deficiency
 Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV). By signing this form, I also agree on behalf of myself and my De-
 pendents that, to the extent permitted by law, health care providers, insurers, claims administrators, employers, and others may disclose my Enrolled Family’s
 personal information including individually identifiable health information that may include diagnosis, prognosis, treatment, and payment information related to
 physical and/or mental illness including substance abuse, AIDS, ARC, or HIV to CHC Carolinas for CHC Carolinas' administration of health insurance benefits
 including treatment, payment, or health care operations purposes and other purposes permitted by law.
 I HAVE READ AND AGREE TO THE STATEMENTS ABOVE. (SIGNATURE REQUIRED BELOW)

 _________________________________________________________________________                           ___________________________________________
 Applicant Signature                                                                                 Date

 _________________________________________________________________________
 Applicant Printed Name




NC SM GRP 1-25 09-11                                                                                                                                             4 of 4
                                                               Enrollment/Change Form
                                                                            26+ Employees
            *Denotes required fields for enrollment. For items with ** please select a Reason for Enrollment OR a Reason for Change.
 A    EMPLOYER INFORMATION: To Be Completed By Employer
 ☐    New Group                   ☐    New Enrollment                     ☐    Change                  ☐    Waive
 Company Name:                                                                          *Group No.:


 *Date Employed Full Time:                                                              *Effective Date of Coverage or Change


          Pre-existing conditions exclusion period is 12 months unless you provide proof of coverage (Certificate of Creditable Coverage) from your prior plan(s).
                      **REASON FOR ENROLLMENT                                                                       **REASON FOR CHANGE:
                                                                                                     (Please check all that apply and include supporting documentation.)

      New Group                                   New Hire                                   Enroll Dependent                          Terminate Dependent
      COBRA                                       Retired                                    Terminate Subscriber                      Name Change (Previous Name)
      Open Enrollment                             Qualifying Event (Reason)                  Address/Phone                             _____________________________
                                            Date:                                       Termination Reason:
                                            __________________________                       Group Request                 Member Request                      Deceased
 EMPLOYEE STATUS:
 ☐ Active         ☐ COBRA            ☐ Salary         ☐ Hourly / Number of hours a week _____                    ☐ Other ___________________________________
 B    SUBSCRIBER INFORMATION
 I ELECT THE FOLLOWING PLAN FOR MYSELF AND MY DEPENDENTS: ☐ None/Waive (please complete Section F and G)
 ☐ Coventry Health Care of the Carolinas, Inc. POS ___ ☐ Coventry Health Care of the Carolinas, Inc. HMO ___ ☐ Other __________________
 Type of Coverage:    ☐ Employee ☐ Employee/Spouse ☐ Employee/Children ☐ Employee/Spouse/Children
 *Last Name                                                                              *First Name                                                                MI


 *Gender                                     *Birthdate                                                     *Social Security Number
 ☐ Male ☐ Female
 *Address


 *City                                                                                      *State                 *ZIP Code


 Email Address


 Marital Status (please check one.)               ☐ Single/Widowed             ☐ Married          ☐ Divorced           ☐ Separated
 Work Phone                                  Home Phone                                  Primary Care Provider
                                                                                         PCP #:                                          PCP Name:
 C    FAMILY MEMBERS TO BE COVERED OR DELETED
 If address and phone numbers of covered dependents are different from that of policy holder, please attach that information on a separate sheet of paper.

      Add              *Last Name                                                        *First Name                                                                MI
      Delete
 *Gender               *Relationship           Disabled              *Birthdate                                *Social Security Number
      Male                   Spouse                 Disabled
      Female                 Child                                   Primary Care Provider
                             Other __________________                PCP #:                                     PCP Name:
      Add              *Last Name                                                        *First Name                                                                MI
      Delete
 *Gender               *Relationship           Disabled              *Birthdate                                *Social Security Number
      Male                   Spouse                 Disabled
      Female                 Child                                   Primary Care Provider
                             Other __________________                PCP #:                                     PCP Name:


NC 26 PLUS (with SOH) 09-11                                                                                    Coventry Health Care of the Carolinas, Inc. (CHC Carolinas)   1 of 4
*Applicant Name: ________________________________________ (required)
       Add          *Last Name                                              *First Name                                                     MI
       Delete
 *Gender            *Relationship        Disabled          *Birthdate                          *Social Security Number
       Male               Spouse             Disabled
       Female             Child                            Primary Care Provider
                          Other __________________         PCP #:                              PCP Name:
       Add          *Last Name                                              *First Name                                                     MI
       Delete
 *Gender            *Relationship        Disabled          *Birthdate                          *Social Security Number
       Male               Spouse             Disabled
       Female             Child                            Primary Care Provider
                          Other __________________         PCP #:                              PCP Name:
 D     PRIOR HEALTH INSURANCE INFORMATION AND OTHER MEDICAL AND/OR PHARMACY COVERAGE INFORMATION
 D1 PRIOR HEALTH INSURANCE
  This section MUST be completed to receive credit for prior coverage and REDUCE or ELIMINATE any applicable waiting period.
     Have you had any health insurance within the last sixty-three (63) days?
         Yes         No            If YES, complete below and provide certificate of coverage:
 Name, Address, and Phone Number of Health Insurance Company


 Policy Number                        Policyholder Name                                      Policyholder Date of Birth (mmddyy)


 Effective Date (mmddyy)                    Termination Date or Expected Termination Date (mmddyy)               If other coverage will remain in
                                                                                                                effect, write N/A in term box, and
                                                                                                                 complete section below.
 Family Members Covered             List Names and Relationships:


 Have you or any family dependents been a previous Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) Plan           ☐ Yes ☐ No
 member?
 If YES, then dates and ID numbers:
                                        NOTICE ABOUT YOUR PRE-EXISTING CONDITION LIMITATIONS
 This plan imposes a pre-existing condition exclusion for all employees and dependents whether they are timely or late enrollees. This means that if
 you have a medical condition before coming to our plan, you may have to wait a certain period of time before the plan will provide coverage for that
 condition. This exclusion applies only to conditions for which medical advice, diagnosis care or treatment was recommended or received within a
 six-month period. Generally, this six month period ends on the day before your coverage becomes effective. However, if you were in a waiting period
 for coverage, the six-month period ends on the day before the waiting period begins. The pre-existing condition exclusion does not apply to children
 under 19 years old, to pregnancy, nor to a child who is enrolled in the plan within 31 days of birth, adoption or placement for adoption or foster care.
 Eligible children (newborns, adoptive children, foster children) are not subject to this exclusion period when enrolled more than 31 days after one of
 the events listed above if your coverage type or the premiums owed are not affected by adding the child. When applicable, this exclusion may last up
 to 12 months from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the
 length of this exclusion period by the number of days of your prior "creditable coverage."
 Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break
 in coverage of at least 63 days. To reduce the 12 month exclusion period by your creditable coverage, you should give Coventry Health Care of the
 Carolinas, Inc. (CHC Carolinas) a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior
 health coverage, Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) will help you obtain one from your prior plan or issuer. There are also
 other ways that you can show you have creditable coverage. Please contact Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) if you need
 help demonstrating creditable coverage. Throughout this notice, all references to “you” are meant to refer to both the employee and their dependents.
 D2    When coverage with CHC Carolinas begins, will you or any of your family members have any other medical insurance                       Yes
       coverage? If you answered yes, please complete below.                                                                                  No
 COVERAGE TYPE:           ☐ Group Policy ☐ Individual Policy ☐ Medicare ☐ Pharmacy ☐ Medicaid ☐ Tricare ☐ Other __________________
 Other Insurance Company Name                   Policy Holder Name                           Covered Dependents


 Relationship                      Gender           Birthdate                                      Effective Date of Other Insurance
      Spouse          Child           Male
      Other _______________           Female




NC 26 PLUS (with SOH) 09-11                                                                                                                           2 of 4
*Applicant Name: ________________________________________ (required)
 Other Insurance Company Name                    Policy Holder Name                            Covered Dependents


 Relationship                       Gender          Birthdate                                       Effective Date of Other Insurance
     Spouse           Child             Male
     Other _______________              Female
 Medicare Information
 ☐ Subscriber or ☐ Dependent                                Dependent's Last Name                                       Reason for Medicare Eligibility

                                                                                                                        ☐ Over 65
                    Effective Date Of:                      Dependent's First Name                              MI      ☐ Disabled
 Part A                                                                                                                 ☐ Kidney Disease (ESRD)
 Part B                                                     Medicare #                                                  ☐ ALS (Lou Gehrig's Disease)
 Part D
 ☐ Subscriber or ☐ Dependent                                Dependent's Last Name                                       Reason for Medicare Eligibility

                                                                                                                        ☐ Over 65
                    Effective Date Of:                      Dependent's First Name                              MI      ☐ Disabled
 Part A                                                                                                                 ☐ Kidney Disease (ESRD)
 Part B                                                     Medicare #                                                  ☐ ALS (Lou Gehrig's Disease)
 Part D
 E    HEALTH INFORMATION
 (Please answer each question fully and accurately. Incomplete answers could delay the processing of your requested coverage.)
 Please provide the health history of you and your family members who will be covered on this application. Please CIRCLE all applicable condi-
 tions and provide details for all "YES" answers in the appropriate section. Conditions include but are not limited to the following:
 1    Acquired Immune Deficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV), Alcohol or Drug Abuse,
      Arthritis, Cancer, Diabetes, Disorder of the neck/back/spine, Heart conditions, Intestinal, Liver (Cirrhosis, Hepatitis
      B, C, or D), Lung conditions, Organ transplant, Stroke, or Vascular (blood vessel) disorders (Circle all that apply           ☐ YES           ☐ NO
      and give details below)
 2    Any surgery or medical treatment discussed, planned, or recommended?
      (Please give full details below)                                                                                              ☐ YES           ☐ NO
 3    Is anyone currently pregnant?
                                                                                                                                    ☐ YES           ☐ NO
      If YES, Due Date: _______/________/___________ (Month/Day/Year)
 4    Are there any other medical conditions not listed above?
      (Please give full details below)                                                                                              ☐ YES           ☐ NO
 5    Anyone currently taking any prescription medication(s)?
      (Please give full details below)                                                                                              ☐ YES           ☐ NO
                  Please give full details for all "Yes" questions above. Additional pages may be used but must be signed and dated.
                                                                                                Medications (oral,
                                                                          Treatment                                      Is further treatment needed? If yes,
 Question Number              Person's Name          Condition                               injectable, infusion, or
                                                                         (Month/Year)                                                please explain
                                                                                                    inhaled)




NC 26 PLUS (with SOH) 09-11                                                                                                                               3 of 4
*Applicant Name: ________________________________________ (required)
                                                                                                      Medications (oral,
                                                                              Treatment                                        Is further treatment needed? If yes,
 Question Number              Person's Name              Condition                                 injectable, infusion, or
                                                                             (Month/Year)                                                  please explain
                                                                                                          inhaled)




 F    WAIVER        My employer has given me an opportunity to apply for group health coverage for myself and my dependents (if applicable)

 I have declined to apply for coverage for  ☐ myself, ☐ spouse, ☐ dependents
 Reason for decline:     ☐ Other health insurance ☐ Spousal coverage ☐ Other reason (please explain)
 _____________________________________________________________________________________________________________________
 I understand that if I decide to apply for health coverage for myself and any applicable dependents at a later date, neither my dependents nor I will
 be eligible for coverage until (1) my employer’s next open enrollment period, or (2) there is a qualifying event as defined in the EOC.

 ____________________________________________________________________________                                  ___________________________________
 Employee Signature (only if you are waiving coverage)                                                         Date:
 G    CONDITIONS OF ENROLLMENT                             Please read the following carefully.
 I hereby apply for membership or request a change in membership in this Coventry Health Care of the Carolinas, Inc. (CHC Carolinas) Plan. I understand that
 my enrollment and benefits are in accordance with those described in the applicable Evidence/Certificate of Coverage and Group Contract. I authorize 1) all
 health providers and insurers to furnish CHC Carolinas, and 2) all health providers and CHC Carolinas to furnish all insurers and health providers records con-
 cerning me or any member of my family for whom information is requested for any purpose required for the coverage of benefits including, but not limited to, the
 coordination of payments with other insurers or in connection with the provision of medical care. I understand that I or my authorized representative is entitled
 to receive a copy of this form containing this authorization for disclosure of information. A photographic copy of this authorization shall be valid as the original.
 I authorize my employer to deduct from my wages the amount required (if any) to cover my contribution for coverage. I certify that all the above information is
 correct. For claim adjudication purposes, this authorization is valid for the duration of my coverage for health benefits through CHC Carolinas. For purposes of
 collecting information for an insurance policy application, policy reinstatement, or a request for change in policy benefits, this authorization shall remain valid
 for thirty months from the date the authorization is signed. It is further understood that CHC Carolinas reserves the right to re-rate coverage if any supplied
 information is materially inaccurate or incomplete, or rescind coverage in the event of fraud or intentional material misrepresentation.
 AGREEMENT AND AUTHORIZATION
 By signing this form, I agree on behalf of myself and those family members enrolled in this CHC Carolinas Plan (Dependents) for whom I have authority to enroll
 and to consent on their behalf (collectively my Dependents and I shall be referred to as Enrolled Family) that CHC Carolinas may use or disclose to third parties
 the information contained on this enrollment form and individually identifiable health information relating to my Enrolled Family for purposes of administering
 my health insurance benefit including treatment, payment, or health care operations, as those terms are explained in detail in CHC Carolinas' Notice of Privacy
 Practices and to the extent permitted by law. My Enrolled Family’s consent includes agreement for the use or disclosure of health information that may include
 diagnosis, prognosis, treatment, and payment information related to physical and/or mental illness, including substance abuse, Acquired Immune Deficiency
 Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV). By signing this form, I also agree on behalf of myself and my De-
 pendents that, to the extent permitted by law, health care providers, insurers, claims administrators, employers, and others may disclose my Enrolled Family’s
 personal information including individually identifiable health information that may include diagnosis, prognosis, treatment, and payment information related to
 physical and/or mental illness including substance abuse, AIDS, ARC, or HIV to CHC Carolinas for CHC Carolinas' administration of health insurance benefits
 including treatment, payment, or health care operations purposes and other purposes permitted by law.
 I HAVE READ AND AGREE TO THE STATEMENTS ABOVE. (SIGNATURE REQUIRED BELOW)

 _________________________________________________________________________                           ___________________________________________
 Applicant Signature                                                                                 Date

 _________________________________________________________________________
 Applicant Printed Name




NC 26 PLUS (with SOH) 09-11                                                                                                                                      4 of 4
                                         Provider Nomination Form
This form will provide the minimum amount of information necessary for CHC Carolinas Network Management department to
pursue contract discussion with provider practices and facilities interested in becoming a participating provider with CHC
Carolinas and the associated networks managed by CHC Carolinas in North and South Carolina.

‘Submitted by’ Information – very important for Network to be able to follow up with you if needed.
Your name: ___________________________________              Submitted on (date): _______________

Your telephone number: (____) ___________________          Your email address: ___________________________________


Line of Business
CHC Carolinas will attempt to contract all Nominee’s with an ‘all-product’ contract that encompasses all the Coventry product
lines of business. If any one line of business is more of a priority for this nomination, please indicate below by checking the box
above the logo/name:




                                    Nominee Information (*required information)

Office Contact Person Name: ________________________                 Office Name*: __________________________________

Office Contact Person Telephone: (___) _______________               Office Street Address*: ___________________________

Office Contact Email: ______________________________                 City, State, Zip*: _________________________________

Office Tax ID Number: ____________________________                   County Name: __________________________________

Office Telephone: (____) __________________________                  Specialty(s): if known   ___________________________

                                                                                              ___________________________


Provider Name(s)*: ________________________________                  ____________________________________

                    ________________________________                 ____________________________________



Please complete and mail this form to:                                    Or fax to: 919-337-1888
CHC Carolinas                                                             Attn: Network Contracting Coordinator
Attn: Network Contracting Coordinator
2801 Slater Road, Suite 200                                               Or email to:
Morrisville, NC 27560                                                     ContractNominations@cvty.com


Once this Nomination Form is received at CHC Carolinas, we will contact the practice to discuss participation in the network. If
interested, an application and contract will be sent.

                                                                                                                          Rev 1/2013
                                    (Please circle or highlight your Coventry Health Care, Inc. plan name)
Carelink                              CHC of the Carolinas                  CHC of Georgia                                            CHC of Iowa
CHC of Kansas, Kansas City            CHC of Kansas, Wichita                CHC of Louisiana                                          CHC of Nebraska
Group Health Plan (GHP)               HealthAmerica/HealthAssurance

                                                              Medical Claim Form


Patient Information Complete this section only if claim is for a qualified dependent.
 Last Name                                First                              MI                If age 19 or over     Student      Disabled
                                                                                                If student, give name of school, city and state
 Member Number/Suffix           Date of Birth        Relationship               Sex




Medicare Information Complete this section only if patient is eligible for Medicare.



Other Health Insurance or HMO Coverage If Yes, complete section below or claim cannot be processed.    No other coverage
Name of Policyholder                          Policy Number                                     Name of Insurance Company

Street Address                                                                     City                               State                Zip


Authorization/Release of Information
I authorize any insurance company, organization, employer, hospital physician, pharmacist or other health care provider to release any
information requested with regard to this claim and the expenses reported. I certify that the information furnished in conjunction with this claim is
true and correct. I know it is a crime to fill out this form with facts I know are false or to omit facts I know are important.

Patient or authorized person‘s signature______________________________________________                         Date ________________

I agree to assign benefits directly to the provider of services: -_____________________________________________________
                                                                    Patient or authorized person‘s signature Date
                                           !!!! THIS SECTION INTENDED FOR PHYSICIANS ONLY!!!!
                                                IF A DETAILED STATEMENT IS AVAILABLE, PLEASE ATTACH
!Provider Statement of Services Rendered
Name and Address of Facility where services were rendered (If other than home or office)                               Date Admitted             Date Discharged

Diagnosis Code and Description
1.
2.
Date of Service    Place of   CPT-4 Procedure Code    Description of Service                                            Charges       Days or
From/To            Service                                                                                                            Units




Signature of Provider                                                                                                 Total           Amount             Balance
                                                                                                                      Charge          Paid               Due
Provider Name                                                           Tax I.D. Number
                                                                                                                         Please mail this completed form to:
Provider Address                                                       Telephone Number                                  The claim address listed next to the name of
                                                                                                                         your health plan listed on the attached page.
       HOW TO COMPLETE THIS MEDICAL CLAIM FORM


1. The Employee or Authorized Person must complete the following sections of the Benefit
   Claim Form:

   o   Employee Information
   o   Patient Information
   o   Accident Information
   o   Medicare Information
   o   Other Health Insurance
   o   Authorization/Release of Information

   This claim cannot be processed unless all sections are completed. Claims for services
   provided by a nonparticipating provider must be submitted on this Benefit Claim Form.

2. Assignment of Benefits
   If the provider is not a Participating Provider, the decision whether or not to assign benefits is
   between you and the provider.

3. Submitting the Claim Form
    If the provider is not a Participating Provider, you are responsible for filing the claim.

                                            Send claims to:

Carelink - PO Box 7373, London, KY 40742

CHC of the Carolinas - PO Box 7715, London, KY 40742

CHC of Georgia - PO Box 7711, London, KY 40742

CHC of Iowa - PO Box 7709, London, KY 40742

CHC of Kansas - PO Box 7109, London, KY 40742

CHC of Louisiana - PO Box 7707, London, KY 40742

CHC of Nebraska - PO Box 7705, London, KY 40742

Group Health Plan (GHP) - PO Box 7374, London, KY 40742

HealthAmerica/HealthAssurance (Central PA) - PO Box 7089, London, KY 40742

HealthAmerica/HealthAssurance (Western PA) - PO Box 7088, London, KY 40742
                                   Health, Allergy & Medication Questionnaire (HMQ)
Your answers to the following questions will help protect you against potentially harmful drug interactions and side effects.
We will alert your pharmacist about possible drug allergies and interactions that can be harmful. To best serve you, we
need to know if you have any medication allergies or medical conditions. We also need to know what prescription and
nonprescription medications you take regularly.

Your privacy is important to us. Medco complies with federal privacy regulations and will protect this information.
Follow the steps listed below.
Step 1: Verify and complete information in SECTION 1.
Step 2: Complete all sections below using blue or black ink. Please print.
Step 3: Return the completed questionnaire in the self-addressed envelope with your mail-order form or refills. If you
do not have a preaddressed envelope, please return the questionnaire to:
                                             Medco Health Solutions, Inc.
                                             4865 Dixie Highway
                                             Fairfield, OH 45014
                                             Attn: HMQ

  SECTION 1: Patient information
  Patient name:                                                          Gender:

  Month/Year of birth:                                                   Contact phone:

  Patient member number:
  (Located on your member ID card and/or in your benefit information.)




  SECTION 2: Your medication allergies

  Fill in the oval completely if you have had an allergy or serious reaction to any of these medications:

            Aspirin and salicylates (for example: ZORprin®, Trilisate®)
            Codeine (for example: Tylenol® #3)
            Erythromycin, Biaxin®, Zithromax®
            Nonsteroidal anti-inflammatory drugs (NSAIDS) (for example: ibuprofen, Advil®, Motrin®)
            Penicillins/cephalosporins (for example: Amoxil®, amoxicillin, ampicillin, Keflex®, cephalexin)
            Sulfa drugs (for example: Septra®, Bactrim®, TMP/SMX)
            Tetracycline antibiotics
   If you have an allergy to a medication that is not listed above, print the name of that medication
   in the space below. Example: morphine
   other:
   other:
                                                                                                (over, please)
                                                                                                (over, please)


                  JCMLPRF 4/09                                                            04/09     A030
SECTION 3: Your medical conditions
Has your doctor ever told you that you have any of the conditions listed below? If so, fill the oval completely next to all that apply.
           Allergies, hay fever (allergic rhinitis)                            Heart failure (CHF)
           Arthritis                                                           Hemophilia and hemophilia-like conditions
           Asthma                                                              High blood pressure (hypertension)
           Bladder control problem (urinary incontinence)                      High blood sugar (diabetes)
           Brittle bones (osteoporosis)                                        High cholesterol (hypercholesterolemia)
           Chest pain (angina)                                                 Inflammatory bowel disease
           Crohn’s disease                                                     Migraine headache
           Depression                                                          Overactive thyroid (hyperthyroid)
           Emphysema (COPD, chronic bronchitis)                                Peptic, stomach, or duodenal ulcer
           Enlarged prostate (benign prostatic hyperplasia,                    Poor circulation in the legs (peripheral
           BPH)                                                                vascular disease)
           Gastric reflux, heartburn, or esophagitis (GERD)                    Seizures (epilepsy)
           Glaucoma                                                            Stroke (TIA)
         Heart attack (myocardial infarction)                   Underactive thyroid (hypothyroid)
If you have a medical condition that is not listed above, print the name of that medical condition in the
space below. Example: breast cancer
other:
other:

SECTION 4: Your nonprescription medications
Fill in the oval completely for each nonprescription medication that you are currently taking on a regular basis.
           Advil®/ibuprofen                                                    Prilosec OTC®/omeprazole
           Aleve®/naproxen                                                     Sominex®, Nytol®/diphenhydramine
           Bayer®/aspirin                                                      Tagamet®/cimetidine
           Benadryl®/diphenhydramine                                           Tylenol®/acetaminophen
           Orudis KT®/ketoprofen                                               Zantac®/ranitidine
           Pepcid AC®/famotidine
If you take a nonprescription medication that is not listed above, print the name of that medication in
the space below.
other:
other:


SECTION 5: Patient prescription medications*
Please list the prescription medications you are currently taking in the space below. *Information
can be found on the prescription labels. If none, please check here. [ ] NONE




                     Did you complete both sides?                             Thank you very much.

         JCMLPRF                                                                                                A030
Direct Claim Form/Coordination of Benefits
See the back for instructions. Complete all information.
An incomplete form may delay your reimbursement.

Member/Subscriber Information See your prescription drug ID card.                                                         Direct Claim Receipts
                                                                                                                          Tape receipts or itemized bills on the back.
Group No.                                                                                                                 See back for details.
Member ID                                                                                                                 Check the appropriate box if any
                                                                                                                          receipts or bills are for a:
                                                                                                                          „ Compound prescription
Member Name (First, Last)
                                                                                                                             Make sure your pharmacist lists ALL
                                                                                                                             the VALID 11-digit NDC numbers
Street Address                                                                                                               and ingredients and quantities on
                                                                                                                             the receipt or bill.
City                                                                   State           Zip                                „ Medication purchased outside of
                                                                                                                             the United States
Patient Information                                                                                                          Please indicate:
                                                                                                                             Country
                                                                                                                             Currency used
Patient Name (First, Last)                                                                                                „ Allergy medication
Patient Date of Birth (Month/Day/Year)
                                                                                                                          Coordination of Benefits
Sex          Relationship to Plan Member
„ Female „ 1 Self                     „ 5                                  Disabled Dependent                             (Another Health Plan has paid a
„ Male       „ 2 Spouse               „ 6                                  Dependent Parent                               portion) Mark the appropriate box for
             „ 3 Eligible Child       „ 7                                  Nonspouse Partner                              your primary coverage method. See the
             „ 4 Dependent Student „ 8                                     Other                                          back for more information.
                                                                                                                          Is this a coordination of benefits claim?
Pharmacy Information
                                                                                                                          „Yes           „No
                                                                                                                          „ 1 Another Health Plan paid and you
Name of Pharmacy                                                                                                                 are enclosing a statement that
                                                                                                                                 outlines how much you paid and
Street Address                                                                                                                   how much the other carrier paid.
                                                                                                                          „ 3 Card Program
City                                                                   State           Zip                                „ 4 Medco Pharmacy/mail-order service
Telephone (include area code)                                                                                             Any person who knowingly and with intent
                                                                                                                          to defraud, injure, or deceive any insurance
Is this an on-site nursing home pharmacy? „Yes                                                              „No           company submits a claim or application containing
I hereby certify that the charge(s) shown for the medication(s) prescribed is correct and agree to provide Medco or its   any materially false, deceptive, incomplete, or
agents reasonable access to records related to medication dispensed to this patient in accordance with applicable law.    misleading information pertaining to such claim
I further recognize that reimbursement will be paid directly to the plan member and assignment of these benefits to       may be committing a fraudulent insurance act,
a pharmacy or any other party is void.
                                                                                                                          which is a crime and may subject such person to
                                                                                                                          criminal or civil penalties, including fines and/or
X                                                                                                                         imprisonment or denial of benefits.*
Signature of Pharmacist or Representative                              NABP Number Required
(Required)                                                                                                                Please tape receipts on the back.
Acknowledgment
I certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself)
am eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury or covered under
another benefit plan. I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or
any other party is void.


X
Signature of Member                                                                                                                                              CF84125 8-10
Direct Claim Receipts
Please tape your receipts here. Do not staple! If you have additional receipts, tape them on a separate piece of paper.

   Tape receipt for prescription 1 here.                                                Tape receipt for prescription 2 here.

   Receipts must contain the                                                           Receipts must contain the
   following information:                                                              following information:
   • Date prescription filled                                                          • Date prescription filled
   • Name and address of pharmacy                                                      • Name and address of pharmacy
   • Doctor name or ID number                                                          • Doctor name or ID number
   • NDC number (drug number)                                                          • NDC number (drug number)
   • Name of drug and strength                                                         • Name of drug and strength
   • Quantity and days’ supply                                                         • Quantity and days’ supply
   • Prescription number (Rx number)                                                   • Prescription number (Rx number)
   • DAW (Dispense As Written)                                                         • DAW (Dispense As Written)
   • Amount paid                                                                       • Amount paid
                   PHARMACY INFORMATION (For Compound Prescriptions ONLY)
• List the VALID 11-digit NDC number for                                                            Date                           Days’
  EACH ingredient used for the compound             Rx #
  prescription.                                                                                     filled                         supply
• For each NDC number, indicate the “metric
                                                                         VALID 11-digit NDC #                                             Quantity
  quantity” expressed in the number of
  tablets, grams, milliliters, creams, ointments,
  injectables, etc.
• For each NDC number, indicate cost per
  ingredient.
• Indicate the TOTAL charge (dollar amount)
  paid by the patient.
• Receipt(s) must be attached to claim form.                                                              Total quantity
                                                                                                           Total charge
Use this form for Direct Claims and Coordination of Benefits
• You must complete a separate claim form for each pharmacy used and for each patient.                     Instructions
• You must submit claims within 1 year of date of purchase or as required by your plan.                    Read carefully before completing this form.
                                                                                                           1. Be sure your receipts are complete. In
• For Coordination of Benefits claims only
                                                                                                              order for your request to be processed, all
   You must first submit the claim to the primary insurance carrier. Once the statement from the              receipts must contain the information
   primary plan is received from the primary carrier, complete this form, tape the original                   listed above. Your pharmacist can provide
   prescription receipts in the spaces provided above, and attach the statement from the primary              the necessary information if your claim or bill
   plan, which clearly indicates the cost of the prescription and what was paid by the primary plan.          is not itemized.
   Prescription Drug Programs or HMO Plans                                                                 2. The plan member should read the
   Retail pharmacies: If the primary plan is one in which a co-payment or coinsurance is paid at              acknowledgment carefully, and then sign
   the pharmacy, then no EOB is needed. Just complete this form and attach the prescription                   and date this form.
   receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The                    3. Return the completed form and
   receipt(s) will serve as the EOB.                                                                          receipt(s) to:
   Medco Pharmacy™ mail-order service: If the primary plan is mail order, complete this form                  Medco
   and attach either the prescription receipt(s) that shows the co-payment or coinsurance amount              P.O. Box 14236
   paid to the mail-order pharmacy or the statement of benefits you receive from the mail-order               Lexington, KY 40512
   pharmacy.

* California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents
  false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
  Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
  insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information
  concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and
  civil penalties.

Visit us online anytime at www.medco.com.                        *CF84125*
CF84125     8-10                                                          *CF84125*
Mail-Order Exclusion List
Plan approved maintenance medications are available through mail order if the member’s
employer has purchased a mail order benefit. Maintenance medications are those drugs that are
needed for long-term or chronic conditions such as high blood pressure or diabetes. Some of the
drugs that are excluded are listed below and include non-maintenance medications, all controlled
substances, and self administered injectables. Members may call Member Services at one of the
following telephone numbers, to inquire about whether specific medications are covered through
mail order.


Medications Not Covered Through Mail-Order
Antibiotics
Examples include - Amoxil, Augmentin, Biaxin, Ceclor, Ceftin, Duricef, Dynapen, Erythromycin,
Keflex, Lorabid, Omnicef, Pediazole, Pen Vee K, Principen, Trimox, Veetids, Zithromax, Zyvox

Antiemetics
Examples include - Anzemet, Emend, Kytril, Zofran

Antifungals
Examples include - Diflucan, Griseofulvin, Lamisil, Nizoral, Nystatin, Sporanox, Vfend

Cancer Drugs (oral)
Examples include – Gleevec, Iressa, Nexavar, Sutent, Sprycel, Tarceva, Temodar, Tykerb,
Xeloda, Zolinza (does not include Nolvadex (tamoxifen))

Controlled Substances
All controlled substances are excluded from mail-order.
Examples include drugs in the following classes:

    •   Opioids – Darvocet, MS Contin, Opana, Opana ER, Oxycontin, Percocet, Vicodin,
    •   Antianxiety – Ativan, Valium, Xanax
    •   Stimulants – Adderall, Adderall XR, Concerta, Focalin, Focalin XR, Provigil, Ritalin,
        Ritalin LA, Vyvanse
    •   Cannabinoids – Marinol
    •   Anabolic Steroids – Androderm, Androgel, Testim,
    •   Sleep aids – Ambien, Ambien CR, Lunesta, Restoril, Sonata,
    •   Miscellaneous – Lyrica

Drugs Dispensed in Limited Quantities
Examples include – Accutane and generic, Clozaril, Elidel, Protopic
Drugs Not Approved for Routine Long Term Use (non-maintenance)
Examples include – Amitiza, Cialis, Levitra, Lotronex, Muse, Toradol (and generic), Valcyte,
Valtrex, Vesanoid, Viagra, Zelnorm

Drugs with Restricted Distribution
Examples include – Revlimid, Thalomid, Xyrem

High Cost Drugs
Drugs with a total cost over $1,500 require prior authorization.
Examples include – Exjade, Kuvan, Rilutek, Revatio, Tracleer, TOBI, Pulmozyme

Migraine Relief Drugs
Examples include – Amerge, Axert, Cafergot, D.H.E 45, Ergotamine, Frova, Imitrex, Maxalt,
Maxalt MLT, Midrin, Migral, Migranal, Relpax, Sansert, Zomig, Zomig ZMT

Self Administered Injectables
Examples include – Actimmune, Apokyn, Arixtra, Avonex, Betaseron, Caverject, Copaxone,
D.H.E. 45, Edex, Enbrel, Epogen, Forteo, Fragmin, Fuzeon, Genotripin, Heparin, Humatrope,
Humira, Infergen, Innohep, Intron-A, Kineret, Leukine, Lovenox, Methotrexate, Miacalcin,
Neupogen, Norditropin, Normiflo, Nutropin, Nutropin Depot, Pegasys, PEG-Intron, Procrit,
Protropin, Rebif, Saizen, Sandostatin, Serostim, Somavert, Vivaglobin

Miscellaneous Agents
Ana-Kit, EpiPen, EpiPen Jr, Twinject
Glucagon Emergency Kit
Diaphragms
Spacers for inhalers
              Medco By Mail                                                                                        *6101*
              ORDER FORM
              1 Member information: Please verify or provide Member information below.
                                                                              Please send me e-mail notices about the status of the
             Member ID:                                                     enclosed prescription(s) and online ordering at:
             Group: CVTYCOM                                                                       @                     .
             Name:                                                              New shipping address:
             Street Address:
             Street Address:
             Street Address:
             City, ST, ZIP:                                                 (Medco will keep this address on file for all orders from this
FOLD HERE




                                                                            membership until another shipping address is provided by any
                                                                            person in this membership.)
            Daytime phone:                                                  Evening phone:
              2 Patient/doctor information: Complete one section for each person with a prescription. If a person has
                  prescriptions from more than one doctor, complete a new section for each doctor (additional sections are on
                  back). Send all prescriptions in the envelope provided.

            First name                                          Last name


            Birth date (MM/DD/YYYY)              Sex             Patient’s relationship to member
                                                    M       F       Self       Spouse      Dependent
            Doctor’s last name                                                      1st initial    Doctor’s phone number


            First name                                          Last name


            Birth date (MM/DD/YYYY)              Sex             Patient’s relationship to member
                                                    M       F       Self       Spouse      Dependent
            Doctor’s last name                                                      1st initial    Doctor’s phone number
FOLD HERE




              3 Complete your order: You can pay by e-check, check, money order, or credit card. Make checks and
                  money orders payable to Medco Health Solutions, Inc., and write your member ID number on the front.
                  Visit www.medco.com or call member services at the number on your ID card to learn more.

            Number of prescriptions sent with this order:
            Payment options:               e-check      Payment enclosed      Credit card          Send bill

            For credit card payments:                                      Credit card number
              Visa      MC     Discover              AmEx       Diners
            Expiration date                                                        I authorize Medco to charge this card for all
                                   X                                               orders from any person in this membership.
             M M Y Y               Cardholder signature
                Rush the mailing of this shipment ($15, cost subject to change). NOTE: This will only rush the shipping,
                not the processing of your order. Street address is required; P.O. box is not allowed.
            COVENTRY
            X00000-00000-000-0000 7/06
                                         Mailing instructions are provided on the back of this form.
            Patient/doctor information continued
            First name                                            Last name


            Birth date (MM/DD/YYYY)             Sex                Patient’s relationship to member
                                                   M       F          Self      Spouse      Dependent
            Doctor’s last name                                                       1st initial   Doctor’s phone number

            First name                                            Last name


            Birth date (MM/DD/YYYY)             Sex                Patient’s relationship to member
FOLD HERE




                                                   M       F          Self      Spouse      Dependent
            Doctor’s last name                                                       1st initial   Doctor’s phone number


            Important reminders and other information
            Check that your doctor has prescribed the maximum               Medco will make all possible efforts, as
            days’ supply allowed by your plan (not a 30-day supply),        appropriate by law, to substitute generic
            plus refills for up to 1 year, if appropriate. Also, ask        formulations of medication, unless you or your
            your doctor or pharmacist about safe, effective, and            doctor specifically directs otherwise.
            less expensive generic drugs.                                      Pennsylvania and Texas laws permit pharmacists to
            Complete the Health, Allergy & Medication                       substitute a less expensive generic equivalent for a
            Questionnaire.                                                  brand-name drug unless you or your doctor directs
            There may be a limit to the balance that you can carry          otherwise. Check the box if you do not wish a less
            on your account. If this order takes you over the limit, you    expensive brand or generic drug.
            must include payment. Avoid delays in processing by             Please note that this applies only to new prescriptions
            using e-checks or a credit card. (See Section 3 for details.)   and to any refills of that prescription.
            If you are a Medicare Part B beneficiary AND                    For additional information or help, visit us at
            have private health insurance, check your                       www.medco.com or call member services at the
            prescription drug benefit materials to determine the            number on your ID card. TTY/TDD users should call
            best way to get Medicare Part B drugs and supplies. Or,         1 800 759-1089.
            call member services at the number on your ID card. To
            verify Medicare Part B prescription coverage, call
            Medicare at 1 800 MEDICARE (1 800 633-4227).
FOLD HERE




             Place your prescription(s), this form,
             and your payment in the envelope
             provided. Be sure the Medco address
                                                                              MEDCO HEALTH SOLUTIONS OF FORT WORTH
             shows through the window. Do not use                             PO BOX 650322
             staples or paper clips.                                          DALLAS TX 75265-0322

             COVENTRY
                                                                              !7526503228!
Coventry Select, Coventry Choice, and CoventryOne are underwritten by Coventry Health Care of the Carolinas, Inc.
               Coventry Preferred is underwritten by Coventry Health and Life Insurance Company.




                                                                                                                    CHC.CAR.ADMIN.0213

				
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