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Administrative

Explanation of Benefits Statement (EOB) Claims Continuation and Complaint and Medicare Coverages Grievance Procedures

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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....................................... 3 Online Account ManagementSM

Useful Tools for Plan Administration ........................ 4 Access Online Account Management...................... 5

Eligibility Provisions

Who is Eligible to Enroll ..............................................15

Provider Search

Search for Providers in Coventry Health Care of Kansas Provider Networks ............................ 6 Get Directions................................................................... 7

Premium Billing

Accounts Receivable ....................................................16 Premium Payments ......................................................16 Premiums Due First Day of the Month ..................16 Billing Cycle .....................................................................16 Grace Period ....................................................................17 Termination for Non-Payment of Premium .........17 Sample Billing Statement...........................................18

My Online ServicesSM ................................................ 8 Benefits

Schedule of Benefits and Applicable Riders ............ 9

Certificate/Evidence of Coverage

About the Certificate/Evidence of Coverage and Agreement ................................................................ 9

Explanation of Benefits Statement (EOB)

Definition of an EOB Statement ...............................19 Sample EOB Statement ...............................................20

Contractual Agreements

About your Contractual Agreements ....................10

Claims

Out-of-Area Services ....................................................22 Preauthorization ............................................................22 Coordination of Benefits ............................................22

Enrollment and Termination Procedures

Open Enrollment ...........................................................11 Documentation Required to Enroll ........................11 Enrollment Documentation ......................................12 Off-Cycle Enrollment Documentation ...................12 Enrolling a Member ......................................................13 Disenrolling a Member ...............................................13 Copy of Enrollment/Change Form ..........................14

Continuation and Medicare Coverages

Complaint and Appeal Process ................................23 Continuation of Coverage..........................................23 Federally Mandated Coverage (COBRA) ...............23 State-Mandated Coverage.........................................25 State Continuation .......................................................25 Medicare...........................................................................25 Medicare Secondary Payor ........................................25 Companies with 20 or More Employees ...............26 Companies with 19 or Fewer Employees .............26

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Key Contact Information

Quick Reference Guide

Coventry Health Care of Kansas, Inc.

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM

8320 Ward Parkway Kansas City, MO 64114

Main: 816-221-8400 or Toll Free: 866-795-3995

Web address: www.chckansas.com

Enrollment Department for Questions Regarding:

· Status of Enrollment forms · Termination, Additions, Changes, Corrections · Dependent/student verification

888-296-3337

Fax: 866-287-6594

Coventry Health Care of Kansas, Inc. Enrollment Department P.O. Box 2778 Bismarck, ND 58502

Billing Department for Questions Regarding:

· Billing statement · Payment history · Reconciliation questions

888-296-3337

Fax: 866-635-9392

Coventry Health Care of Kansas, Inc. Billing Department P.O. Box 2778 Bismarck, ND 58502 Coventry Health Care of Kansas, Inc. P.O. Box 6512 Carol Stream, IL 60197-6512

Premium Payment:

Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Online Account Management Tech Support: Customer Services for Questions Regarding:

· ID Card request · Member Verification · Claims/Benefits · Provider Status

866-667-3059 800-969-3343

Fax: 866-229-6403

First Help:

· Provides medical advice · Available 24 hours a day

800-622-9528 866-211-2417

Web address: www.eyemedvisioncare.com

EyeMed Vision Discount Program:

· Plan #9240086

MHNet Behavioral Health:

· Mental Health/Substance Abuse Information

866-607-5970

Web address: www.mhnet.com

Medical Management Authorization:

· Pre-authorization · Pharmacy Pre-authorization Line

Medco:

· Medco Rx Bin: 610014 · Rx Group: CVTYCOM

877-837-8914 877-215-4098 800-378-7040

Fax: 866-341-2409 Fax: 877-554-9139

Mail order address: P.O. Box 650322, Dallas, TX 75265-0322 Web address: www.medco.com

Coventry Dental:

· Enrollment / Billing · Member Services

888-296-3337 866-690-4908

Fax: 240-283-3591

Web address: www.cvtydental.com

Claims Addresses:

Medical Claims

Coventry Health Care of Kansas Claims P.O. Box 7109 London, Kentucky 40742

Mental Health Claims

MHNet Behavioral Health P.O. Box 7802 London, KY 40742

Dental Claims

Coventry Dental P.O. Box 7402 London, KY 40742

Medco Claims

Medco P.O. Box 14711 Lexington, KY 40512

www.chckansas.com

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Customer Service: 866-611-7337

Online Account Management

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

SM

Useful Tools for Plan Administration

At Coventry Health Care, we know administrative needs are different. So we give you a convenient way to manage your group health benefits online. Through a single, passwordprotected 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: · View up to six months of billing statements and invoices · View payment history · View eligibility information for any employee, and find invoices on which that employee appeared · Access online bill payment · Add/terminate employee or dependent coverage · Update employee demographics · Perform a wide variety of functions on behalf of any covered member, including viewing/requesting ID cards and updating address/phone, etc.

Request Cert. of Creditable Coverage

· Request Certificates of Creditable Coverage · Ask questions · Request quantities of literature · View service request status

www.chckansas.com

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Customer Service: 866-611-7337

Online Account Management

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

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-- Continued

Access Online Account Management

Employers can sign up to use Online Account Management through an easy four-step process detailed below. · Log on to www.chckansas.com and visit the "Employers" home page · Follow the instructions to get to the Online Account Management section and read the Coventry Health Care, Inc. Electronic Commerce Agreement online · Complete the Web Account Request Form online · Once the request is processed, the Employer Administrator will be e-mailed a login ID and password to begin using Online Account Management

The Employer Administrator can use Online Account Management to establish access for other Employer Users, including the insurance broker. Security for additional users can be limited to access specific functionality as deemed appropriate. Our dedicated Net Support team is available Monday ­ Friday, 8 a.m. to 6 p.m. (EST) to help with problems or questions using Online Account Management. Simply call toll free 866-667-3059 for personal assistance.

www.chckansas.com

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Customer Service: 866-611-7337

Provider Search

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online Services Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

SM

It's easy for you and your members to find an in-network provider using our electronic provider search tool. It contains the names, addresses and phone numbers of our participating providers, hospitals, pharmacies, outpatient facilities and other ancillary providers in our network.

Search for Providers in Coventry Health Care of Kansas Provider Networks

Prior to seeking services, members are responsible for reviewing the provider directory on the website to ensure they seek care from Coventry Health Care providers. To search for in-network physicians, hospitals and ancillary providers such as physical therapy and urgent care facilities on our website: · Go to www.chckansas.com · Select "Plan Members" in the middle of the page · Click on "Locate a Provider" on the left or right side of the page · Click on "Enter Provider Search" · Select a product from the drop-down list (refer to the product identified on the member ID card) · Search for a doctor, hospital or ancillary service provider · Specify provider name, county or distance/mileage preferences to begin your search

www.chckansas.com

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Customer Service: 866-611-7337

Provider Search -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Get directions

Select a product from the drop-down list.

Members can obtain a map and driving directions to the provider they've selected by simply clicking "display 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 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 whether a provider participates in our network.

www.chckansas.com

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Customer Service: 866-611-7337

My Online Services

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

SM

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 personal health record (PHR). Personal Health Record · View, store, track and maintain personal health information · Share with a health care provider, family member or caregiver Transactions · View medical and prescription claims · View or print explanations of benefits (EOB) · View, request or print an image of an ID card · Send a secure e-mail to Coventry · Update personal information Health and wellness · Take a health risk assessment · Request an e-mail reminder for screenings and tests · Access Coventry WellBeingSM with a wealth of online wellness programs Cost and Quality tools · Search for network providers · Find costs for procedures and services with My Cost of Care · Save on prescription drugs · Compare hospital quality ratings

www.chckansas.com

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Customer Service: 866-611-7337

Benefits

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Schedule of Benefits and Applicable Riders

These documents inform your employees about their benefits and out-of-pocket costs. We have included the schedule(s) of benefits, and any applicable riders your company chose for its health care benefit plan, as attachments in your electronic welcome kit. These actual benefit descriptions were given to each employee during the enrollment process. Contact your account manager or Customer Service if you would like a copy sent to you.

Certificate/Evidence of Coverage

About the Certificate/Evidence of Coverage and Agreement

In general, the Certificate/Evidence of Coverage (COC or EOC), as well as the Group Master Contract, explains to your employees how to access their covered services. The Group Master Contract is the legal agreement between the contract holder and Coventry Health Care, for the provision and receipt of covered services. This agreement describes the benefits, exclusions, and limitations, terms, conditions and scope of coverage.

It is important that you and your employees become familiar with the COC/EOC document. The Kansas/Missouri Department of Insurance considers the Certificate/Evidence of Coverage to be the legal document your employees and their dependents are bound by law to follow. Your electronic welcome kit contains an attached copy of the Certificate/Evidence of Coverage that is available to those employees enrolled with Coventry Health Care. Copies of the Certificate/Evidence of Coverage may also be obtained either through Customer Service or on our website, www.chckansas.com or at www.coventry-ekits.com.

!

Important Notice!

www.chckansas.com

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Customer Service: 866-611-7337

Contractual Agreements

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online Services Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

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About your Contractual Agreements

The contractual agreement(s) detail the following: · Coverage under your health care benefit plan · Coverage effective date · Eligibility for coverage · Group enrollment waiting period · When monies are due · How agreement(s) may be terminated We have included in your welcome kit a copy of the contractual agreement(s) signed by both an authorized representative from your company and your local Coventry Health Care of Kansas Chief Executive Officer.

www.chckansas.com

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Customer Service: 866-611-7337

Enrollment and Termination Procedures

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

OR: 2. Mail or fax a signed, completed paper enrollment/change form to us. Address and fax information is located on page three of this manual (Key Contact Information: Enrollment Department).

The enrollment and disenrollment procedures that follow are standard for all Coventry Health Care customers. The procedures specific to your company, if any, are detailed in the Group Master Contract attachment received in your electronic welcome kit.

!

Important Notice!

Open Enrollment

It is important that you understand the difference between an open enrollment period and an off-cycle enrollment: · An open enrollment period is the time period designated by your company when eligible employees are offered the option to choose, change or reallocate benefits. Open enrollment may occur anytime up to 60 days prior to your plan year renewal and lasts approximately 30 days. Your account manager will help to plan the open enrollment period and is available to conduct onsite educational meetings, distribute enrollment literature, and coordinate the processing of any necessary paperwork. · 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. All enrollment forms for dependent changes must be received by Coventry within 31 days of the qualifying event.

Documentation Required to Enroll

Employees and eligible dependents may enroll during the open enrollment period or during the off-cycle enrollment. Coventry offers two ways to enroll employees and their dependents: 1. Use our convenient online system through Online Account Management. It's free and simple to use!

Section 111 of the Federal Medicare, Medicaid and SCHIP Extension Act of 2007 carries mandatory reporting requirements with respect to persons who have coverage under a group health plan. Part of the required data to be reported includes enrollee Social Security Numbers (SSNs). Therefore, we seek to collect SSNs for all covered employees and dependents in the event the health plan must report enrollee data.

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Important Notice!

www.chckansas.com

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Customer Service: 866-611-7337

Enrollment and Termination Procedures -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Enrollment Documentation

To enroll your employees and their eligible dependents, a completed enrollment/change form for each employee and his or her eligible dependents must be submitted to the Enrollment department or processed via Online Account Management. The following four common circumstances may require you to submit additional documents during the open enrollment period: 1. When a spouse's last name is different from the employee's. You may be required to submit a copy of the marriage certificate or applicable court decree as proof of marriage. 2. When the dependent child's last name is different from the employee's. In this instance you may be asked to submit either: a. A copy of the dependent child's birth certificate indicating both parents' last name(s). b. For a stepchild, a copy of the first page of the employee's last Federal Income Tax Form 1040 as proof that the dependent child is claimed as a dependent of the employee. Coventry Health Care, Inc. may also require the employee to sign and have notarized an affidavit attesting that the stepchild resides permanently in the employee's home. 3. When the employee enrolls an out-of-area student. Our Passport Program allows out-of-area students to be covered as in-network. Your employee will receive a letter from Coventry's Enrollment department if additional documentation is required. 4. When the employee enrolls a disabled dependent. An additional form may be required to 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 periodically review the eligibility of disabled dependents. There are also some uncommon circumstances that occur with an employee and/or dependent who wishes to enroll during the open enrollment period. When these uncommon circumstances occur, your account manager may ask you to submit documents other than those listed above. Ultimately, it is your responsibility to verify the dependent status of your company's participating employees.

Off-Cycle Enrollment Documentation

The eligibility provisions as they relate to off-cycle enrollment for new and existing employees and their eligible dependents are detailed in your Group Master Contract and/or the Certificate/Evidence of Coverage.

www.chckansas.com

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Customer Service: 866-611-7337

Enrollment and Termination Procedures -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Enrolling a Member

As your company's benefit administrator, you have a significant role in the enrollment process. It is important that you understand and follow it. Coventry will not accept any retroactive enrollments beyond 60 days from the date the member becomes eligible to enroll. You distribute enrollment packets to eligible employees. The enrollment packets typically contain a group enrollment form, schedule of benefits and applicable riders. The six-step enrollment process is as follows: 1. Each employee and his or her dependents carefully reviews the information in the enrollment packet. 2. The employee completes and submits to you an enrollment form and any additional documentation that is required, as explained in the previous section, "Enrollment Documentation." The enrollment form must be submitted within 31 days of the employee, or their dependent(s), becoming eligible for coverage. 3. You review the enrollment form to ensure it is completely filled out. Also, you need to make sure the employee has signed the enrollment form and 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 on the form.) 4. Process the enrollment using Coventry's Online Account Management website. Otherwise, ensure the enrollment form is complete and any additional documentation is attached to it, submit all documentation to the Enrollment department (see Key Contact Information page for fax number). Submitting the enrollment form at least three weeks prior to the effective date of coverage will allow enough processing time to ensure the employee receives an identification card prior to seeking services. 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. 6. Coventry mails each employee and dependent an identification card. In the unlikely event a member does not have his or her identification card by the first day of coverage, the member may print a temporary ID card through My Online Services; or, with access to Online Account Management, you can print a temporary ID card for any employee. *Please note: Newborns are automatically covered for the first 31 days. Newborn coverage must be added within 31 days of the birth of the newborn in order for benefits to continue, even if family coverage is already in place.

Disenrolling a Member

As your company's benefit administrator, you are responsible for notifying our Enrollment department when you disenroll an employee or a dependent. You can perform a disenrollment through our Online Account Management website. To disenroll manually, you can simply provide a completed enrollment/change form to the Enrollment department (see Key Contact Information page for fax number) for processing. The enrollment/change form should clearly indicate the date benefits terminate, which may differ from the individual's employment

www.chckansas.com

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Customer Service: 866-611-7337

Enrollment and Termination Procedures -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online Services Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

SM

termination date. Once an employee is terminated, a Certificate of Creditable Coverage is sent to each covered member as required by the Health Insurance Portability and Accountability Act (HIPAA). Please be aware that Coventry Health Care does not prorate premiums for terminated employees. It is important that you understand and follow this disenrollment process. Coventry will not accept any retroactive disenrollments beyond 60 days from the date the member became ineligible for benefits or requested disenrollment. Coventry Health Care may generally disenroll employees and dependents when the employee and/or dependents: · Fail to pay all copayments, coinsurance, deductibles, penalties, and premium contributions and bills for unauthorized or uncovered services · Misuse the member identification card · Fail to cooperate with the coordination of benefits · Become ineligible for benefits Provisions related to member disenrollment are detailed in your Group Master Contract and the Certificate/Evidence of Coverage.

Copy of Enrollment/Change Form

An electronic version is included in this manual. You should save this document and print the enrollment/change form as needed.

www.chckansas.com

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Customer Service: 866-611-7337

Eligibility Provisions

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Who is Eligible to Enroll

Please review this section of your Group Master Contract or Certificate/Evidence of Coverage carefully. Failure to abide by eligibility provisions may result in loss of coverage for an employee and his or her dependents. This section includes the following important information: · Who is eligible to enroll in your company's health care benefit plan

The eligibility provisions specific to your company, if any, are detailed in the Group Master Contract and/or the Certificate/Evidence of Coverage attachments to this administrator kit.

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· When coverage begins for enrolled employees and their dependents

Important Notice!

www.chckansas.com

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Customer Service: 866-611-7337

Premium Billing

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

The billing provisions that follow (i.e., the premium due date, billing cycle, grace period and termination provisions) are standard among all of our customers. The billing provisions specific to your company, if any, are detailed in the Contractual Agreement(s) attached to your electronic welcome kit.

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Important Notice!

Accounts Receivable

The address and phone number of our Billing department is listed in the Key Contact Information on page three of this manual. A representative is available to answer any questions you may have regarding your invoice. You should also contact an accounts receivable representative if you are unable to pay 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.

Premium Payments

Using the Online Account Management tool is the easiest way to pay your bill. In fact, 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 Management tool. If you are not using Online Account Management, please pay as billed. Your payment check must be sent with the remittance copy. You will need to submit your terminations 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.

Premiums Due First Day of the Month

You have agreed to pay your monthly premium on or before the first day of the upcoming month. In return, we have agreed to pay our providers to provide services to your employees and their dependents for that month.

Billing Cycle

Employer groups typically receive their Premium Invoice by the 10th of each month. Your bill is prepared on or about the fifth day of each month, preceding the month for which premium is due. Premium is due upon receipt, but no later than the first day of the coverage month for which the group is being billed. Remember, a copy of the invoice should be returned with payment. If you do not receive your invoice, or if you have any questions regarding your billing statement, call our Billing Department (the phone number is listed on the Key Contact Information page located in the front of this manual).

www.chckansas.com

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Customer Service: 866-611-7337

Premium Billing -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Grace Period

Provisions related to the grace period are detailed in the Group Master Contract attached to your welcome kit.

Termination for Non-Payment of Premium

When termination occurs because of nonpayment of premium, it is your responsibility, as your company's benefit administrator, to notify those employees with Coventry Health Care coverage that their coverage is terminated. These employees, and their 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.

www.chckansas.com

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Customer Service: 866-611-7337

Sample Billing Statement

Table of Contents Key Contact Information Online Account ManagementSM

00005464 598 101464

HOW TO READ YOUR PREMIUM INVOICE

1

Group Number: Invoice Number: Invoice Date: Due Date: Coverage Period: 1234567890 1234567 06/01/2006 1 07/01/2006 07/01/2006 to 7/31/2006

Please make check payable to:

Health Plan

CONTACT NAME 1234 MAIN STREET ANYTOWN USA 12345-0000

PO BOX 11111 CITY ST 12345-1234

2 2

This is an example of your group number & pertinent invoice information that should be referenced when making payments if you choose to not use the coupon provided. The lockbox address you should use to mail in premium payments. Account Summary ­ A summary of payments and/or adjustments applied to your account since the last invoice period. New Charges for Coverage Period ­ Premium charges for the CURRENT coverage period. Retro Active Charges for Coverage Period ­ Premium charges/credits for PRIOR periods that have not been billed to you on previous invoices. Current Monthly Charges ­ This amount represents the total monthly charges for this particular coverage period (Items 4 & 5 combined). Account BalancePayment Due ­ This is the amount you owe, less any payments not reflected in Item 3 above.

Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

3

Prior Account Balance $129,822.00 Payments Received $129,304.00 Health Plan Adjustments $0.00 Current Month Premium $164,879.00 Retro Premium (+/-) $10,489.00

*

Account Balance

$175,886.00

Account Summary

Prior Month Transactions Date Totals Prior Month's Statement Balance 05/09/06 $ 129,822.00 Payment Received Since Last Statement 05/09/06 $ 64,177.00 Payment Received Since Last Statement 05/14/06 $ 65,127.00 3 Health Plan Adjustments $ 0.00 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Unpaid Balance From Prior Periods $ 518.00 New Charges for Coverage Period Premium Detail 16 E3 $ 35,737.00 20 FAM $ 37,649.00 30 E1 $ 48,094.00 11 EMP $ 23,814.00 16 E&SP $ 19,585.00 94 Total Contracts $ 164,879.00 4

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

4

Retro Active Charges for Prior Period Current Monthly Charges *Account Balance ­ Payment Due

$

10,489.00

5 6 7

5

$ 175,368.00 $ 175,886.00

*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 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. Come visit our website at www.cvty.com.

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CUSTOMER COPY

00250676300000003155589

Page 3 of 6

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We are also available 24 hours a day to service you at www.cvty.com where in a personalized, secure environment you can: · View and Print Your Invoice · Review Your Covered Employees/Dependents · Add, Remove or Change Covered Employees/Dependents So, come check us out soon!

www.chckansas.com

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Customer Service: 866-611-7337

Explanation of Benefits Statement (EOB)

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Definition of an EOB Statement

The EOB statement is a document that provides members a detailed description of how their claim was processed. An EOB is not a bill, but members are encouraged to review these carefully and to contact Customer Service with any questions. A subscriber will generally receive an EOB statement if the following events occur: · The provider has been paid for the covered services furnished to the member · The member was responsible for payment in the form of coinsurance, deductible, penalty or full payment NOTE: EOBs are available through My Online ServicesSM. EOBs are not typically generated for services that are covered in full or covered with only a member copayment.

Sample EOB Statement

A sample EOB statement is on the following page. The statement provides an explanation of each section of the statement.

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Customer Service: 866-611-7337

Sample EOB Statement

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online Services Benefits Certificate/Evidence of Coverage Contractual Agreements

1

HOW TO READ YOUR EXPLANATION OF BENEFITS (EOB)

What is an explanation of benefits (EOB)? An EOB is a notification from Coventry Health Care explaining how your medical claim(s) are processed (including a payment or denial).

1 The address to which the EOB 1.

was mailed.

2 Group Name--the payor of your medical 2.

claim. If your company is a self-funded group, their name will appear here.

3 Insured--the person who holds the 3.

contract with the insurer. 4. 4 Patient--the person who received medical services. This may be a subscriber or a dependent.

5 ID Number--the identification for the 5.

person receiving medical services.

6 Claim Number--document control 6.

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Is an EOB a bill from the insurance company? No, Coventry Health Care does not bill members for medical services. Coventry Health Care processes and pays the claims submitted from your provider or hospital.

number generated by Coventry Health Care. If you need to call a customer service representative to discuss the claim, this is an important number to give them.

7 Provider--the provider of your medical 8.

service. This could be an individual practice or facility.

Coventry Health Care Management Corporation In Trust for Self Funded Group 3721 TecPort Dr P Box 67103 .O. Harrisburg PA 17106

Page 1 of 2

8 Member Responsibility--this is the 9.

THIS IS NOT A BILL

EXPLANATION OF BENEFITS Our organization processes and pays the claims submitted from your health care provider(s). You have received this Explanation of Benefits (EOB) as our notification to you explaining how your medical claim(s), including payments or denials, are being processed.

amount the member may be responsible to pay the provider.

9 Date--the date your medical services 7.

were incurred.

10 Procedure Code/Description--the

Member, Mrs. 630000 M RD NOWHERE PA 15555

Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Payments made on behalf of:

2 3 4 5

coverage category for which the code is classified.

11 Billed Amount--the total amount billed to

GROUP NAME

Member, Mrs. Member, Mrs. GROUP 85XXXXXXX01 01/23/08

Insured: Patient: Group Name: ID Number: Date:

Coventry Health Care by your physician.

12 Contractual Adjustment--reductions

**Payments made at the time services were rendered are not reflected on this statement**

6 Claim Number: 18 Plan Paid: 8 Member Responsibility: 2XXXXX879 $77.27 $10.00

**Provider billing address may differ from physical office location**

Provider: Provider Billing Address:

7 M GENTS 710 ELM STREET ALLENTOWN, PA 18109-2732

in payment due to network savings, coordination of benefits, or non-covered services. For more information, see number 19, Cont. Rmk/Other Rmk.

13 Approved Amount--the amount

Other Rmk

8 Service Date From - To Billed Procedure Code/Description Amount 11 9 01/23/08 $118.00 99244/MEDICINE 10 TOTALS: 6 Claim Number: 18 Plan Paid: 8 Member Responsibility:

$118.00

Contractual Adjustment 12

$30.73 $30.73

Approved Amount 13

$87.27 $87.27

Member's Responsibility to Provider

Copay 14

$10.00 $10.00

Coins 15

$0.00 $0.00

Deduct. 16

$0.00 $0.00

Other 17

$0.00 $0.00

Plan Paid 18

$77.27 $77.27

Cont. Rmk

/

19

Coventry agrees to pay the provider for services rendered minus copays, coinsurance or deductibles, if applicable.

14 Less Copay 15 Less Coinsurance 16 Less Deductible

9XXXXXX2 $751.00 $0.00

Provider: Provider Billing Address:

7 WEST SLEEP MEDICINE 1260 MADISON STREET ALLENTOWN, PA 18109-2729

**Provider billing address may differ from physical office location**

8 Service Date From - To Procedure Code/Description 9 01/23/08 95810/MEDICINE 10 TOTALS: Billed Amount 11

$1,200.00 $1,200.00

Contractual Adjustment 12

$449.00 $449.00

Approved Amount 13

$751.00 $751.00

Member's Responsibility to Provider

Copay 14

$0.00 $0.00

Coins 15

$0.00 $0.00

Deduct. 16

$0.00 $0.00

Other 17

$0.00 $0.00

Plan Paid 18

$751.00 $751.00

Cont. Rmk

/

Other Rmk

17 Less Other Amounts 18 Plan Paid--the amount paid by

19

your plan.

19 Cont. Rmk/Other Rmk--a Coventry

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 incorrectly billed, contact a customer service representative using the toll free number listed below.

Health Care code that explains why certain amounts were not paid.

www.chckansas.com

20

Customer Service: 866-611-7337

Sample EOB Statement -- Continued

Table of Contents Key Contact Information

A

HOW TO READ YOUR MEMBER BENEFIT USAGE

Benefits Header

B

Benefit Period Header

C

Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements

C

Benefit Accumulation Summary

A

The amounts below include claims processed as of February 23, 2009. The information does not reflect any claims received or adjusted after the above mentioned date.

B

January 1, 2009 ­ December 31, 2009.

Deductible Dollars Type Year-to-Date Satisfied Maximum $ Remaining $ Out-of-Pocket Dollars Year-to-Date Satisfied Maximum $ Remaining $

Enrollment and Termination Procedures Eligibility Provisions Premium Billing

2 1

1

2

3

4

5

6

7

Type

5

Year-to-Date Satisfied

6 7

Maximum $ Remaining $

Year-to-Date Satisfied

Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

3

Maximum $

4

Remaining $

0108

www.chckansas.com

21

Customer Service: 866-611-7337

Claims

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

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. Members may send us a question via secure e-mail through My Online Services. For your reference, we have provided some helpful information below: Claim status codes · 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. · 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 Coventry Customer Service for further explanation. For questions about a status other than those described, members may use the "ask a question about this claim" function after clicking on the claim in question.

Out-of-Area Services

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

Preauthorization

Preauthorization, also known as prior authorization or pre-certification is required for some services. To avoid having claims denied, members should be sure to have providers contact the Medical Management department before receiving these services. A list of these services can be found on My Online Services or in the Certificate/Evidence of Coverage.

Coordination of Benefits

Coventry Health Care does coordinate benefits when a member may be covered by two or more insurers. For information regarding benefit determination and coordination of benefit rules please see the Certificate/Evidence of Coverage. When a claim is received that may involve coordination of benefits, third party liability, or worker's compensation, a questionnaire is sent to the subscriber to further investigate details surrounding the claim. Members will receive a letter indicating their claim is being reviewed and will require additional information before being processed. Once the requested information is received and returned, our systems are updated with any relevant information and all related claims are processed accordingly. Failure to return this questionnaire will delay claims processing. Coventry Health Care does not exclude pre-existing conditions from coverage.

www.chckansas.com

22

Customer Service: 866-611-7337

Continuation and Medicare Coverages

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Complaint and Appeal Process

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 Certificate/Evidence of Coverage or plan document for a complete description of the complaint and appeal process.

Continuation of Coverage

When an employee's coverage is terminated, your company is required to offer the terminated employee, and applicable dependents, federally mandated continuation of group coverage (COBRA) or state-mandated continuation of group coverage. The attached Certificate/ Evidence of Coverage summarizes both of these coverage types for your employees and their dependents.

The following explanation of COBRA and Kansas/Missouri state 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 or state continuation of group coverage. When an employee is hired, you are responsible for informing the employee of the availability to continue group coverage. In the event group coverage is terminated, you are responsible for notifying the employee and dependents of their eligibility to continue group coverage.

!

Important Notice!

Federally Mandated Coverage (COBRA)

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 current group health care benefit plan to members who have one of the following qualifying events: · 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 dependents for up to 18 months. · A dependent whose coverage ceases under the terms of the Group Master Contract ("Plan"), or because of divorce, legal separation, the subscriber's death or the subscriber becoming eligible for Medicare, or if there is a loss of a child's dependent status under the terms of the plan. Coverage for 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. Coverage for the employee and his or her dependents may be continued for 29 months if the Social Security Administration determines 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 days of the date of the determination and within the initial 18-month COBRA continuation period.

www.chckansas.com

23

Customer Service: 866-611-7337

Continuation and Medicare Coverages -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

· In cases of Chapter 11 bankruptcy, a retiree and his or her dependents may be considered qualified beneficiaries within one year before or after the employer filed for bankruptcy. Retirees may continue coverage until their death. The retiree's dependents may continue coverage until the earliest of either the dependent's death or 36 months past the death of the retiree. · 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 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 their dependents within 44 days of the event. The 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. · The Plan Administrator must notify the individual of his or her right to continue coverage under COBRA by providing an enrollment/change form and the applicable COBRA rates and the notice required under COBRA. Note: Coventry Health Care does not administer COBRA coverage and is not the Plan Administrator. 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 has an independent right to elect continuation of coverage. You may require the member to pay the full cost of the 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. · Employees who elect to continue coverage under COBRA should submit the enrollment/change form with the first month's premium to the Plan Administrator within the specified time. · When the individual wishes to discontinue coverage or coverage expires, the Plan Administrator should submit an enrollment/change form terminating the individual from the coverage. 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. It is important to note that the Federal Government 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.

www.chckansas.com

24

Customer Service: 866-611-7337

Continuation and Medicare Coverages -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

State-Mandated Coverage

Any state-mandated coverage applicable to your employee and their family is explained in the Group Master Contract, and/or Certificate/Evidence of Coverage.

State Continuation

State Continuation legislation allows employees of employers who are not required to offer COBRA to maintain group health insurance when their coverage under their plan would normally end. Group coverage under Kansas/Missouri law may continue up to eighteen (18) months, or mirror COBRA. Refer to the Certificate/Evidence of Coverage for specific guidelines.

Medicare

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

Medicare Secondary Payor

Medicare Secondary Payor Recovery Demands are letters sent by CMS (the Centers for Medicare and Medicaid Services) asking an employer or the health plan to reimburse claim dollars that CMS believes should have been the responsibility of the health plan. This occurs when Medicare originally paid a claim as the primary insurer, but should have actually paid as the secondary insurer. If you receive a copy of one of these demand letters, immediately forward the entire package of materials (they are sometimes quite large) to: Coventry Health Care Attention: Compliance Department 8320 Ward Parkway Kansas City, MO 64114

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 employees and their spouses in the Certificate/Evidence of Coverage. For further information, contact your local Social Security Office.

!

Important Notice!

www.chckansas.com

25

Customer Service: 866-611-7337

Continuation and Medicare Coverages -- Continued

Table of Contents Key Contact Information Online Account ManagementSM Provider Search My Online ServicesSM Benefits Certificate/Evidence of Coverage Contractual Agreements Enrollment and Termination Procedures Eligibility Provisions Premium Billing Explanation of Benefits Statement (EOB) Claims Continuation and Medicare Coverages

Companies with 20 or More Employees

If you are an employer with 20 or more employees, the actively working Medicare-eligible employee or his or her spouse is covered by your company's group health care benefit plan as the primary payor of covered health care services. Therefore, Medicare is the secondary payor if the Medicare-eligible employee elects to participate in Medicare.

Companies with 19 or Fewer Employees

If you are an employer with 19 or fewer employees, Medicare is the primary payor of the covered health care services for an actively working Medicare-eligible employee or spouse. The Medicare-eligible employee or spouse may have secondary coverage through your company's benefit plan. If your company is to provide secondary coverage, it is your responsibility to complete the enrollment/change form and submit it to the Enrollment department. It is also your responsibility to disenroll any Medicare-eligible employees or spouses who do not choose secondary coverage under your company's benefit plan. To disenroll an employee or spouse, complete the enrollment/change form and submit it to the Enrollment department.

If you have questions or need further assistance, please visit our website at www.chckansas.com or contact your account manager.

www.chckansas.com

26

Customer Service: 866-611-7337

Check all that apply:

COVENTRY HEALTH CARE OF KANSAS, INC COVENTRY HEALTH AND LIFE INSURANCE COMPANY PREFERRED HEALTH SYSTEMS INSURANCE COMPANY (KANSAS ONLY) PREFERRED PLUS OF KANSAS, INC (KANSAS ONLY)

Plan: Selection (Optional): Base Buy-up Buy-down Other:

HMO

POS

PPO

QHDHP

Enrollment and Change Form

DO NOT WRITE IN MARGINS

8320 Ward Pkwy, Kansas City MO 64114 PH: 1-866-795-3995 - Fax: 1-866-287-6594

Group Name:

Group Number:

Employee Name:

Effective Date / Date of Change:

Section A

Last Name First Name City State Street Address

New Enrollment Declining Coverage (go to back page) Name Change Address Change Dependent Address Change Telephone Change Middle Initial Zip Code

Add Dependent(s) Marriage Newborn Adoption QMCSO Other

Cancel Dependent(s) only Marriage Divorce Age Limit Out of Service Area Other

Cancel All Coverage Terminate Employment Voluntary Withdrawal Leave/Layoff Out of Service Area Other

COBRA / State Continuation Death Termination Reduction in Work Hours Divorce/Separation Loss of Eligibility Email Address Home Telephone Number

Reinstatement Return from Layoff Return from leave Rehire Enrollment Error Other

Date of Hire

Work Telephone Number

Section B

Is the Employee on a Leave of Absence? Last Name, First Name, Middle Initial Employee Spouse Child Child Child Child Other Medical Insurance Coverage? Yes No Commercial/Employer Group If yes, please list type: What family members are covered? Self Spouse FMLA Worker's Compensation Disability Birth Date MM/DD/YY Effective date of FMLA, COBRA or Continuation coverage: Sex Social Security Relationship to Status Employee M/F Number

Active On Leave Retired Common Law Married* Disabled Lives with Employee Disabled Lives with Employee Disabled Lives with Employee Disabled Lives with Employee Disabled N/A

Dependent Address (if different than Employee Address)

N/A

Individual Policy

Medicare (Eligibility due to: Age 65 Disability Other and Coverage Includes: Part A Part B Part C Part D) Child(ren) If not all, list: _____________________________________________________________________________________________________________

Policy Holder: ___________________________________________________Insurance Provider: _________________________________________________________ Policy Effective Date:_________________

* Coverage will not be offered to dependents living outside of the service area unless the Dependent Child is a qualified Full-Time Student, or when Dependent Child coverage is required by a court decree (please provide court decree). You must submit affidavit with Enrollment if indicating marriage under Common Law.

KSMOOK-APP-CF-01.10R

2010/05

Agreement and Authorization

Unless waiving coverage below, by signing this form, I am applying for covered services for which my family and I are eligible and I authorize my employer to deduct from my earnings any required contributions. I agree on behalf of myself and those family members enrolled ("Dependents"), for whom I have the authority to enroll and to consent on their behalf (collectively my Dependents and I shall be referred to as my "Enrolled Family"), that Preferred Health Systems Insurance Company, Preferred Plus of Kansas, Inc., Coventry Health Care of Kansas, Inc. and Coventry Health and Life Insurance Company, and/or their authorized representatives (collectively referred to as "Health Plan") 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 for treatment, payment or health care operations, as those terms are explained in detail in Health Plan's Notice of Privacy Practices and to the extent permitted by law. I also agree on behalf of myself and my Dependents, 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, autoimmune deficiency syndrome, AIDS related complex, human immunodeficiency virus or genetic conditions to Health Plan for Health Plan's administration of health insurance benefits, including for treatment, payment or health care operations purposes and other purposes permitted by law. I represent that my answers to the questions on this form are complete and accurate to the best of my knowledge, and I understand that my answers, except for those questions in Section D, will be used to determine eligibility for coverage. If I have, on behalf of myself and my Dependents, performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact, it could provide the basis to reform, refuse or rescind coverage and to refund any premiums paid as though coverage had never been in force. After coverage has been in force for two years, no statement except fraudulent statements I make voids my coverage or reduces my benefits. Plans offered by Preferred Health Systems Insurance Company are underwritten by Preferred Health System Insurance Company. Plans offered by Preferred Plus of Kansas, Inc., are underwritten by Preferred Plus of Kansas, Inc. Plan offered by Coventry Health Care of Kansas, Inc. are underwritten by Coventry Health Care of Kansas, Inc. Plans offered by Coventry Health and Life Insurance Company are underwritten by Coventry Health and Life Insurance Company. I have read and agree to the statements above.

Employee Signature Employee Printed Name

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

Date

INCOMPLETE FORMS WILL BE RETURNED, DELAYING ELIGIBILITY, CLAIMS PROCESSING, RECEIPT OF ID CARDS(S) AND MAY RESULT IN DENIED CLAIMS

Declination of Coverage I Waive Medical Coverage for:

Reason waiving coverage:

Myself (Employee) & Any Eligible Dependents

Spouse

Child(ren)

Covered by other group medical insurance. List insurer:

Other reason (please explain):

If you are waiving/declining medical coverage for yourself or your dependents (including your spouse) because of other medical coverage, you or your dependents may in the future be able to enroll in this plan, provided that you request enrollment within 31 days after your other coverage ends, or within 60 days after losing eligibility for any CHIP or Medicaid subsidy or becoming eligible for any CHIP or Medicaid subsidy. In addition, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days after a marriage, birth, adoption or placement for adoption or within 60 days after losing eligibility for any CHIP or Medicaid subsidy or becoming eligible for any CHIP or Medicaid subsidy. If you are waiving medical coverage for any other reason, or if you fail to complete this form, you may be limited to enrolling only during the annual enrollment period.

Employee Signature Employee Printed Name

Date

KSMOOK-APP-CF-01.10R

2010/05

KS.AD.MAN.0510

Information

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