HomeMy WebLinkAboutResolution - 2006-R0511 - Contract - BCBS, Texas - Medical Admin Services, Network Services, Etc. - 10/13/2006Resolution No. 2006-RO511
October 13, 2006
Item No. 6.10
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute a contract by and between the City of Lubbock and Blue Cross Blue
Shield of Texas to provide medical administrative services (ASO), network services,
utilization review, medical case management, disease management, dental administration
and Health Insurance Portability and Accountability Act (HIPAA), Consolidated
Omnibus Budget Reconciliation Act (COBRA) and Flexible Spending Account (FSA)
administration, pursuant to the contract attached hereto as Exhibit "A".
THAT the City Manager or designee may execute any routine documents and
forms associated with said insurance coverage.
Passed by the City Council this 13th day of October , 2006.
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DAVID A. MILLER, MAYOR
ATTEST:
Reb cca Garza, City Secretaryo
APPROVED AS TO CONTENT:
Leisa Hutcheson, Risk Manager
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of Texas October 13, 2006
Item No. 6.10
ADMINISTRATIVE SERVICES AGREEMENT
This Agreement made effective as of January 1, 2007 by and between Blue Cross and Blue Shield
of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company
(hereinafter referred to as the "Claim Administrator"), and City of Lubbock (hereinafter referred to as
the "Employer"), for the Employer Group Number(s) set forth in the Fee Schedule of Exhibit II attached
hereto, WITNESSETH AS FOLLOWS:
RECITALS
WHEREAS, the Employer's Group Health Plan has established and adopted an employee welfare
benefit plan ("Plan") as described in its plan document, which shall be provided by the Employer to the
Claim Administrator; and
WHEREAS, the Employer on behalf of the Group Health Plan desires to retain the Claim Administrator
to provide certain administrative services with respect to the Plan; and
WHEREAS, it is desirable to set forth more fully the obligations, duties, rights and liabilities of the Claim
Administrator and the Employer, as representative of the Group Health Plan, with respect to the Plan;
NOW, THEREFORE, in consideration of these premises and the mutual promises and agreements
hereinafter set forth, the parties hereby agree as follows:
I. APPOINTMENT
The Employer hereby retains and appoints the Claim Administrator to provide services as
hereinafter described in connection with the administration of the Plan.
II. AGREEMENT DEFINITIONS
"Administrative Charge" means the monthly service charge that is required by the Claim
Administrator for the administrative services performed under this Agreement. The
Administrative Charge(s) is indicated in the most current Fee Schedule specifications of Exhibit
II of this Agreement.
"Certificate of Creditable Coverage" means a document which is generated for Covered
Persons terminating coverage under the Plan. The certificate is provided to Covered Persons as
evidence for credit of health coverage held under the Plan during the term of this Agreement.
"Claim" means notification in a form acceptable to the Claim Administrator that service has
been rendered or furnished to a Covered Person. This notification must set forth in full the
details of such service including, but not limited to, the Covered Person's name, age, sex and
identification number, the name and address of the Provider, a specific itemized statement of
the service rendered or furnished, the date of service, applicable diagnosis, the Claim Charge,
and any other information which the Claim Administrator may request in connection for such
service.
"Claim Charge" means the amount which appears on a Claim as the Provider's regular charge
for service rendered to a patient, without further adjustment or reduction.
HCSC TX ASA Rev. 9/06
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
An Independent Licensee of the Blue Cross and Blue Shield Association
"Claim Payment" means the benefit calculated by the Claim Administrator, plus any related
Surcharges, upon submission of a Claim, in accordance with the benefits specified in the Plan.
All Claim Payments shall be calculated on the basis of the Provider's Eligible Charge for
Covered Services rendered to the Covered Person.
"Covered Employee" shall have the same meaning as defined in the Employer's Plan.
"Covered Person" shall have the same meaning as defined in the Employer's Plan.
"Covered Service" means a service or supply specified in the Plan for which benefits will be
provided.
"ERISA" means the Employee Retirement Income Security Act of 1974, as amended.
"Fee Schedule" means the specifications setting out certain particulars of this Agreement
under Exhibit II of this Agreement including, but not limited to, the Administrative Charge and
other service charges; or any such other subsequent set of specifications supplied by the Claim
Administrator as a replacement to the Fee Schedule under Exhibit II. The specifications or items
of the Fee Schedule shall be applicable for the Fee Schedule Period noted therein, except that
any item of the Fee Schedule may be changed in accordance with such Exhibit's
"COMPENSATION TO CLAIM ADMINISTRATOR" provisions; provided, however, that in no
case shall the Administrative Charges in the Fee Schedule exceed the applicable amounts as
set forth in Exhibit II attached hereto and incorporated herein.
"Fee Schedule Period" means the period of time beginning and ending on the dates shown in
the most current Fee Schedule under Exhibit II of this Agreement.
"Group Health Plan" means, as applied to this Agreement, that certain self—insured employee
welfare benefit plan adopted by Employer on December 15, 2005 by Resolution 2005-R0596,
and amended on April 13, 2006 by Resolution 2006-R0177, and as may be further amended
from time to time, and as defined by Section 160.103 of the Health Insurance Portability and
Accountability Act of 1996, a copy of which has been provided to Claim Administrator.
"HIPAA" means the Health Insurance Portability and Accountability Act of 1996.
"Network" means identified Providers, including physicians, other professional health care
providers, hospitals, ancillary providers, and other health care facilities, that have entered into
agreements with the Claim Administrator (and, in some instances, with other participating Blue
Cross and/or Blue Shield Plans) for participation in a participating provider option health benefit
coverage program, if applicable to the Plan under this Agreement.
"Provider" means any hospital, health care facility, laboratory, person or entity duly licensed to
render Covered Services to a Covered Person or any other provider of medical or dental
services, products or supplies which are Covered Services.
"Provider's Eligible Charge" means (a) in the case of a Provider which has a written
agreement with the Claim Administrator to provide care to Covered Persons at the time Covered
Services are rendered, such Provider's Claim Charge for Covered Services and (b) in the case
of a Provider which does not have a written agreement with the Claim Administrator to provide
care to Covered Persons at the time Covered Services are rendered, such Provider's Claim
Charge for Covered Services, not to exceed the allowable amount therefor as reasonably
determined by the Claim Administrator.
"Supplemental Charge" means a charge for costs due and payable to the Claim Administrator
by the Employer that is separate and apart from the service charges detailed in Exhibit II of this
Agreement. A Supplemental Charge may be applied for any customized reports, forms or other
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
IV.
materials or for any additional services or supplies not documented in the most current Fee
Schedule of Exhibit II. Such services and/or supplies and any applicable Supplemental
Charge(s) are to be agreed upon by the parties in writing prior to the Claim Administrator's
performance and/or provision of such.
"Surcharges" means state or federal taxes, surcharges or other fees, including, but not limited
to World Access Fees, paid by the Claim Administrator which are imposed upon or resulting
from this Agreement.
"Timely" means the following, unless an alternative standard is specified in this Agreement or
is mutually agreed to by the parties in writing:
1. With respect to all payments due the Claim Administrator by the Employer under this
Agreement, within ten (10) calendar days of notification of the Employer by the Claim
Administrator; or
2. With respect to all information due the Claim Administrator by the Employer concerning
Covered Persons, within thirty—one (31) calendar days of a Covered Person's effective
date of coverage or change in coverage status under the Plan; or
3. With respect to all Plan information due the Claim Administrator by the Employer, upon
the effective date of this Agreement and at least ninety (90) calendar days prior to the
effective date of change or amendment to the Plan thereafter.
"World Access Fee" means the Surcharge imposed upon the Claim Administrator for the
administration of an international Claim.
SERVICES TO BE PROVIDED BY THE CLAIM ADMINISTRATOR
During the continuance of this Agreement, the Claim Administrator will perform such services as
set forth in Exhibit I of this Agreement, attached hereto and made a part hereof. The Claim
Administrator, at its sole discretion, may contract with other entities for performance of any of
the services to be performed by the Claim Administrator hereunder; provided, however, the
Claim Administrator shall remain fully responsible and liable for performance of any such
services to be performed by the Claim Administrator but delegated to other entities.
Further, any of the services to be performed by the Claim Administrator under this Agreement
may be performed by the Claim Administrator, or any of its subsidiaries (including any
successor corporation, whether by merger, consolidation, or reorganization), without prior
written approval by the Employer. Any reference in this Agreement to the Claim Administrator
shall include its directors, officers and employees as well as the directors, officers and
employees of any of its subsidiaries and the Claim Administrator shall be responsible and liable
for all performance or failure to perform by such subsidiaries in connection with this Agreement.
CERTAIN RESPONSIBILITIES OF THE EMPLOYER AND THE CLAIM ADMINISTRATOR
A. The Employer retains full and final authority and responsibility for the Plan and its operation.
The Claim Administrator is empowered to act on behalf of the Employer in connection with
the Plan only as expressly stated in this Agreement or as mutually agreed to in writing by
the parties hereto.
B. The Claim Administrator shall have no responsibility for or liability with respect to the
compliance or non—compliance of the Plan with any applicable federal, state and local
rules, laws and regulations; and the Employer shall have the sole responsibility for and shall
bear the entire cost of compliance with all federal, state and local rules, laws and
regulations, including, but not limited to, any licensing, filing, reporting, modification
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
requirements and disclosure requirements as may apply to the Plan, and all costs,
expenses and fees relating thereto; provided, however, the Claim Administrator shall have
the responsibility for and bear the cost of compliance with any federal, state or local laws as
may apply to the Claim Administrator in connection with the performance of its obligations
under this Agreement.
C. Each party shall, to the extent possible, advise the other party of any legal actions against it
or the other party which involve the Plan or the obligations of either party under the Plan or
this Agreement. The Employer shall undertake the defense of such action and be
responsible for the costs of defense; provided, however, that the Claim Administrator shall
have the option, at its sole discretion, to employ attorneys selected by it to defend any such
action, the costs and expenses of which shall be the responsibility of the Claim
Administrator. It is further agreed that each party (provided no conflicts of interest exist)
shall fully cooperate with the other party in the defense of any action arising out of matters
related to the Plan or this Agreement.
D. The Employer acknowledges that unintentional administrative errors may occur. When the
Claim Administrator becomes aware of a Claim overpayment, the Claim Administrator will
make a diligent attempt to recover any such payment. The Claim Administrator, however,
will not be required to enter into litigation to obtain a recovery, unless specifically provided
for elsewhere in this Agreement, nor will the Claim Administrator be required to reimburse
the Plan, except for gross negligence or intentional acts by the Claim Administrator.
E. The Employer shall furnish on a Timely basis to the Claim Administrator certain information
concerning the Plan and Covered Persons as may from time to time be required by the
Claim Administrator for the performance of its duties including, but not limited to, the
following:
1. All documents by which the Plan is established and any amendments or changes to
the Plan.
2. All data as may be required by the Claim Administrator regarding Covered Persons
who are to be covered under this Agreement.
It is the Employer's obligation to Timely notify the Claim Administrator of any change in a
Covered Person's status under this Agreement. All such notifications by the Employer to
the Claim Administrator (including, but not limited to, forms and tapes) must be furnished in
a format mutually agreed to by the parties and must include all information reasonably
required by the Claim Administrator to effect such changes.
F. Clerical errors in keeping or reporting data relative to coverage under this Agreement will
not invalidate coverage that would otherwise be validly in force or continue coverage which
would otherwise validly terminate. Such errors will be corrected by the Claim Administrator
subject to the terms and conditions of this Agreement and the Claim Administrator's
reasonable administrative practices in the administration of the Plan including, but not
limited to, those related to Timely notification of a change in a Covered Person's status.
However, the Employer is liable for any benefits paid for a terminated Covered Person if the
Employer had not Timely notified the Claim Administrator of such Covered Person's
termination.
G. The Claim Administrator will disclose Claim information in accordance with HIPAA privacy
regulations and the Business Associate Agreement entered into by the parties. Further, the
Claim Administrator will provide copies of individual Claim information for a specific
Covered Person, provided that the Employer secures a valid written release from the
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Covered Person specifically related to the Claim information. Upon receipt of the written
request from the Employer and receipt of the Covered Person's written release form, the
Claim Administrator will provide the specified Claim information.
H. In the event the Employer and the Claim Administrator exchange various data and
information electronically, the Employer agrees to transfer on a Timely basis all required
data to the Claim Administrator via electronic transmission on the intranet and/or internet or
otherwise, in a format mutually agreed to by the parties. Further, the Employer is
responsible for maintaining any enrollment applications and change forms completed by
Covered Persons and to allow the Claim Administrator reasonable access to this
information as needed for administrative purposes.
The Employer authorizes the Claim Administrator to submit reports, data and other
information to the Employer in the electronic format mutually agreed to by the parties. In the
event the Employer is unable or unwilling to transfer data in the electronic format mutually
agreed to by the parties, the Claim Administrator is under no obligation to receive or
transmit data in any other format.
I. In the event the Employer directs the Claim Administrator to provide data directly to its third
party consultant and/or vendor, the Employer acknowledges and agrees, and will cause its
third party consultant and/or vendor to acknowledge and agree:
1. The personal and confidential nature of the requested documents, records and other
information (for purposes of this Section W.I., "Confidential Information").
2. Release of the Confidential Information may also reveal the Claim Administrator's
confidential, business proprietary and trade secret information (for purposes of this
Section W.I., "Proprietary Information").
3. To maintain the confidentiality of the Confidential Information and any Proprietary
Information (for purposes of this Section W.I., collectively, "Information").
4. The third party consultant and/or vendor shall:
a. Use the Information only for the purpose of complying with the terms and
conditions of its contract with the Employer.
b. Maintain the Information at a specific location under its control and take
reasonable steps to safeguard the Information and to prevent unauthorized
disclosure of the Information to third parties, including those of its employees not
directly involved in the performance of duties under its contract with the Employer.
c. Advise its employees who receive the Information of the existence and terms of
these provisions and of the obligations of confidentiality herein.
d. Use, and require its employees to use, at least the same degree of care to protect
the Information as is used with its own proprietary and confidential information.
e. Not duplicate the Information furnished in written, pictorial, magnetic and/or other
tangible form except for purposes of this Agreement or as required by law.
5. Not to use the name, logo, trademark or any description of each other or any
subsidiary of each other in any advertising, promotion, solicitation or otherwise without
the express prior written consent of the consenting party with respect to each proposed
use.
6. The third party consultant and/or vendor shall execute the Claim Administrator's then—
current confidentiality agreement.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
7. The Employer shall designate the third party consultant and/or vendor on the
appropriate HIPAA documentation.
8. The Employer shall provide the Claim Administrator with the appropriate authorization
and specific written directions with respect to data release or exchange with the third
party consultant and/or vendor.
To the extent permitted by law, the Employer shall indemnify, defend (at the Claim
Administrator's request) and hold harmless the Claim Administrator and its employees,
officers, directors and agents against any and all losses, liabilities, damages, penalties and
expenses, including attorneys' fees and costs, or other cost or obligation resulting from or
arising out of claims, lawsuits, demands, settlements or judgments brought against the
Claim Administrator in connection with any claim based upon the Claim Administrator's
disclosure to the third party consultant and/or vendor of any information and/or
documentation regarding any Covered Person at the direction of the Employer or breach by
the third party consultant and/or vendor of any obligation described in this Agreement.
J. Referral of Certain Claims/Inquiries
As provided in this Agreement, the Claim Administrator will receive eligibility information, re-
view and process Claims, and respond to customer inquiries; however, the Claim
Administrator does not have final authority to determine Covered Persons' eligibility or to
establish or construe the terms and conditions of the Plan. Therefore, in certain instances,
the Claim Administrator may refer certain Claims to the Employer for review and final
decision. Such referral shall be at the sole discretion of the Claim Administrator.
K. Claim Dispute Resolution
1. After exhaustion of all remedies offered by the Claim Administrator, a Covered Person
may appeal all adverse determinations with the Employer. The Claim Administrator will
cooperate in providing Claim information pursuant to Section N.G. above.
2. On occasion the Claim Administrator may deny all or part of submitted Claims. The
Claim Administrator will provide a full and fair review of any determination of a Claim,
any determination of a request for pre—authorization, and any other determination
made in accordance with the benefits and procedures detailed in the Plan.
L. Final Determination of Claims/Inquiries
The Employer retains the final authority and responsibility to establish and construe the
terms and conditions of the Plan and to determine Covered Persons' eligibility. Certain
claims and/or inquiries will be referred to the Employer for final review and determination in
the following instances:
1. When Claims for services do not appear to qualify for payment under the Plan, claims
or inquiries where there is a question of eligibility, claims where there is a question as
to the amount of payment due, and claims involving litigation or the threat of litigation;
and
2. When a Covered Person chooses to appeal adverse determinations with the Employer
after exhaustion of all remedies offered by the Claim Administrator.
The Employer shall use its best efforts to cooperate with and assist the Claim
Administrator, as applicable, in the performance of its duties hereunder.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
V. CERTIFICATE OF CREDITABLE COVERAGE
The Claim Administrator, at the direction of the Employer, shall issue a Certificate of Creditable
Coverage consistent with the requirements under HIPAA. The Certificate of Creditable
Coverage shall be based upon coverage under the Plan during the term of this Agreement and
information provided to the Claim Administrator by the Employer.
VI. INDEMNIFICATION
A. The Claim Administrator hereby agrees to indemnify and hold harmless the Employer and
its directors, officers, elected officials, and employees against any and all loss, liability,
damages, penalties and expenses, including attorneys' fees, or other cost or obligation
resulting from or arising out of claims, lawsuits, demands, settlements or judgments with
respect to the Plan or this Agreement resulting from or arising out of any acts or omissions
of the Claim Administrator or its directors, officers or employees which have been adjudged
to be (i) grossly negligent, dishonest, fraudulent or criminal or (ii) in material breach of the
terms of this Agreement; provided, however, notwithstanding anything herein to the
contrary pursuant to Section VII.B. below, the Claim Administrator shall be responsible for
the correction of Claim Payment errors by the Claim Administrator.
B. The Claim Administrator does not insure or underwrite the liability of the Employer under
the Plan and has no responsibility for designing the terms of the Plan or the benefits to be
provided thereunder. The Employer retains the ultimate responsibility for claims under the
Plan and all expenses incident to the Plan, except as specifically undertaken in this
Agreement by the Claim Administrator. To the extent permitted by law, the Employer
agrees to indemnify and hold harmless the Claim Administrator and its directors, officers
and employees against any and all loss, liability, damages, penalties and expenses,
including attorneys' fees, or other cost or obligation resulting from or arising out of claims,
lawsuits, demands, settlements or judgments brought against the Claim Administrator in
connection with the design or administration of the Plan, unless the liability therefor was the
direct consequence of the acts or omissions of the Claim Administrator or its directors,
officers or employees and is adjudged to be (i) grossly negligent, dishonest, fraudulent or
criminal or (ii) in material breach of the terms of this Agreement; provided, however,
notwithstanding anything herein to the contrary pursuant to Section VII.B. below, the Claim
Administrator shall be responsible for the correction of Claim Payment errors by the Claim
Administrator.
1. Any claim in connection with a claim for benefits under the Plan.
2. Any claim based upon the disclosure of any information regarding a Covered Person
by the Claim Administrator to the Employer.
3. Any claim in connection with un—Timely and/or inaccurate eligibility data or Claim
information data provided by the Employer to the Claim Administrator, or any such data
provided by the Employer in a format not approved by the Claim Administrator.
4. Any claim arising out of the electronic transfer of data i) from the Employer or the
Employer's third party consultant and/or vendor to the Claim Administrator; or ii) from
the Claim Administrator to the Employer or, pursuant to Section W.I. of this Agreement,
the Employer's third party consultant and/or vendor; including liability arising out of
erroneous, misdirected, intercepted, incomplete or otherwise defective information and
transfers of information, including, but not limited to, garbled transmissions,
transmissions to third parties, and intercepted transmissions.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
5. Any claim arising from the Employer's use or posting of electronic files on the intranet
and/or internet pursuant to Section XI. below.
6. Any claim that may arise from or in connection with the Claim Administrator's
suspension of Claim Payments due to the Employer's failure to pay when due any
amounts owed the Claim Administrator under this Agreement and/or the termination of
this Agreement in accordance with Section VIII. below.
7. Any claim arising from the Employer's directive to the Claim Administrator to print
Employer—assigned unique identification numbers on membership identification cards
or to otherwise use such assigned numbers in violation of any applicable federal, state
and local rules, laws and regulations.
8. Any claim based upon Medicare Secondary Payer ("MSP") laws or regulations.
9. Any claim that may arise from or in connection with the Claim Administrator's issuance
of Certificate(s) of Creditable Coverage based upon un—Timely and/or inaccurate data
provided by the Employer to the Claim Administrator with respect to individuals whose
coverage under this Agreement terminates.
C. Further, Claim Administrator and its directors, officers and employees shall not be liable to
the Employer for loss, liability, damages, penalties and expenses, including attorneys' fees,
or other costs or obligation to the extent resulting from or arising out of third party claims,
lawsuits, demands, settlements or judgments in connection with the design of the Plan and
Employer actions (independently of Claim Administrator's) and written directives of the
Employer in connection with the administration of the Plan by the Employer.
VII. AUDIT AND CORRECTION OF AUDIT ERRORS
A. During the term of this Agreement and within one hundred eighty (180) days after its
termination, the Employer or an authorized agent of the Employer (as mutually agreed to by
the Claim Administrator and the Employer) may, upon at least ninety (90) days prior written
notice to the Claim Administrator, conduct reasonable audits of the Claim Administrator's
records in regard to Claim Payments made under the Agreement. The Employer and such
agent that have access to the information and files maintained by the Claim Administrator
will agree not to disclose any proprietary or confidential information. The Employer, to the
extent permitted by law, and the authorized agent of the Employer shall hold harmless and
indemnify the Claim Administrator in writing of any liability from disclosure of such
proprietary or confidential information. Audits performed on a contingency fee basis will not
be allowed or supported by the Claim Administrator. The Employer will be responsible for
all costs associated with the inspection or audit. All such audits shall be subject to the Claim
Administrator's external audit policy and procedures, a copy of which shall be furnished to
the Employer upon request to the Claim Administrator.
B. The Claim Administrator shall be responsible only for the correction of errors identified in
specific Claim Payments subject to the terms and conditions of the Agreement and shall not
be responsible for errors calculated to exist in a population of Claim Payments on the basis
of a sample drawn from that population. Further, the Claim Administrator has the right to
implement reasonable administrative practices in the administration of this Agreement.
Minor deviations in Claim Payments from the provisions of the Agreement as a result of
such reasonable administrative practices shall not be considered errors.
C. During the term of this Agreement and within one hundred eighty (180) days after its
termination, the Claim Administrator may, upon at least thirty (30) days prior written notice
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
to the Employer, conduct reasonable audits of Employer's membership records with respect
to eligibility.
VIII. TERM AND TERMINATION OF AGREEMENT
This Agreement will continue in full force and effect from the effective date and continue, subject
to appropriation by Employer, for a period of three (3) years therefrom unless terminated as
provided herein.
A. This Agreement may be terminated as follows:
1. By either party upon ninety (90) days prior written notice to the other party; or
2. By both parties on any date mutually agreed to in writing; or
3. By the Claim Administrator if no funds or insufficient funds are appropriated and
budgeted in any fiscal period of the Employer for payments to be made under this
Agreement. In such event, the Employer will notify the Claim Administrator in writing of
that occurrence, and this Agreement will terminate on the earlier of the last day of the
fiscal period for which sufficient appropriation was made or whenever the funds
appropriated for payment under this Agreement are exhausted. Payments due the
Claim Administrator to the date of notification will be made to Claim Administrator.
Upon written request from Claim Administrator, the Employer will provide to Claim
Administrator, the balance of appropriated funds available, when due and payable, for
any calendar year to make payments under this Agreement.
4. By either party, in the event of fraud, misinterpretation of a material fact or not
complying with the terms of this Agreement, upon written notice as provided under
Section XIV. below.
B. In accordance with Exhibit II, Section III.E., of this Agreement, this Agreement may
terminate upon failure of the Employer to pay all amounts due under this Agreement
including, but not limited to, all amounts pursuant to and in accordance with the
specifications of the most current Fee Schedule and Financial Responsibilities provisions of
Exhibit II.
C. The parties hereto further acknowledge and agree that this Agreement shall be effective
only upon the final and timely execution of this Agreement, said execution to occur on or
before November 15, 2006, which the parties acknowledge shall be necessary to effectuate
the terms, conditions, duties, obligations, and responsibilities of the parties under this
Agreement.
The parties hereto further acknowledge and agree that this Agreement shall be effective only
upon the completion and acceptance of the following documents, which shall occur on or
before December 31, 2006.
1. Claims Administrative Document for Managed Health Care; and
2. Claims Administrative Document for Dental Benefits.
The parties agree to the following schedule:
1. Employer shall provide Claims Administrator necessary benefit summaries and
eligibility criteria for Claims Administrator to administer the Plan on or before
November 1, 2006.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
2. Claims Administrator shall provide Employer a proposed document on or before
November 21, 2006.
3. Employer shall provide corrections and comments, if any, to the proposed
document on or before December 8, 2006.
4. Claims Administrator shall provide a new, proposed document to Employer on or
before December 18.
5. Employer and Claims Administrator shall discuss the final document as necessary
to meet the December 31, 2006 deadline.
6. A benefit booklet in PDF format will be made available to Employer to be placed on
its website within ten work days of approval of the Claims Administrative
Document.
If this Agreement is terminated pursuant to this Section VIII., the Employer agrees to notify all
Covered Employees. The parties agree that the Employer will give such notice because the
Employer maintains direct and ongoing communication with, and maintains current addresses
for, all such Covered Employees.
IX. RELATIONSHIP OF PARTIES
A. The Claim Administrator is an independent contractor with respect to the Employer. Neither
party shall be construed, represented or held to be an agent, partner, associate, joint
venturer nor employee of the other.
Further, nothing in this Agreement shall create or be construed to create the relationship of
employer and employee between the Claim Administrator and the Employer; nor shall the
Employer's agents, officers or employees be considered or construed to be considered
employees of the Claim Administrator for any purpose whatsoever.
B. It is understood and agreed that nothing contained in this Agreement shall confer or be
construed to confer any benefit on persons who are not parties to this Agreement including,
but not limited to, employees of the Employer and their dependents.
C. The Employer agrees not to engage any other party to perform the same services that the
Claim Administrator performs hereunder while this Agreement is in effect, unless the
Employer gives notice of termination pursuant to the terms of this Agreement.
D. Notwithstanding anything to the contrary in Section III. above, no part of this Agreement, or
any rights, duties or obligations described herein, shall be assigned or delegated without
the prior express written consent of both parties. Any such attempted assignment shall be
null and void. The Claim Administrator's standing contractual arrangements for the
acquisition and use of facilities, services, supplies, equipment and personnel shall not
constitute an assignment under this Agreement.
E. The Employer hereby acknowledges (i) that an employee welfare benefit plan must be
established and maintained through a separate plan document which may include the terms
hereof or incorporate the terms hereof by reference, and (ii) an employee welfare benefit
plan document may provide for the allocation and delegation of responsibilities thereunder.
However, notwithstanding anything contained in the Plan or any other employee welfare
benefit plan document of the Employer, the Employer agrees that no allocation or
delegation of any fiduciary or non—fiduciary responsibilities under the Plan or any other
employee welfare benefit plan of the Employer is effective with respect to or accepted by
the Claim Administrator.
F. The Claim Administrator is not the plan administrator of the Employer's separate employee
welfare benefit plan as defined under ERISA. It is understood and agreed that (i) the
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Employer has a named Plan Administrator and a Named Fiduciary within the meaning of w
414(g) of the Internal Revenue Code of 1986, as amended; (ii) said Plan Administrator
serves within the meaning of w 3(16)(A) of ERISA; and (iii) the Claim Administrator is not a
fiduciary of the Employer, the Plan Administrator or of the Plan.
G. The Claim Administrator's responsibilities hereunder are intended to be limited to those of a
contract claims administrator rendering advice to and administering claims on behalf of the
plan administrator of the Employer's plan. As such, the Claim Administrator is intended to
be a service provider but not a fiduciary with respect to the Employer's ERISA employee
welfare benefit plan. The Employer represents that its ERISA employee welfare benefit plan
contains the plan procedure described above regarding the designation of responsibilities
under a plan and, accordingly, the Claim Administrator may, pursuant to Sections 402(c)(2)
and 405(c)(1)(B) of ERISA, render advice with respect to claims and administer claims on
behalf of the plan administrator of the Employer's ERISA welfare benefit plan. The Claim
Administrator has no other authority or responsibility with respect to Employer's ERISA
employee welfare benefit plan.
X. PROPRIETARY MATERIALS
The parties acknowledge that each party has developed operating manuals, certain symbols,
trademarks, service marks, designs, data, processes, plans, procedures and information, all of
which are proprietary information ("Business Proprietary Information"). Neither party shall use or
disclose to any third party Business Proprietary Information without prior written consent of the
other party. Neither party shall use the name, symbols, copyrights, trademarks or service marks
("Proprietary Marks") of the other party or the other party's respective clients in advertising or
promotional materials without prior written consent of the other party; provided, however, that
the Claim Administrator may include the Employer in its list of clients.
The Employer acknowledges that the Claim Administrator's Proprietary Marks and Business
Proprietary Information are the sole property of the Blue Cross and Blue Shield Association or of
the Claim Administrator and agrees not to contest the Blue Cross and Blue Shield Association's
or the Claim Administrator's ownership or the license granted to the Claim Administrator for use
of such Proprietary Marks.
The Claim Administrator agrees not to infringe upon, dilute or harm the Employer's rights in its
Proprietary Marks. The Employer agrees not to infringe upon, dilute or harm the Blue Cross and
Blue Shield Association's ownership rights or the Claim Administrator's rights as a licensee in its
Proprietary Marks.
XI. ELECTRONIC DOCUMENTS
The Employer consents to receive via an electronic file or access to an electronic file any
document the Employer requests from the Claim Administrator describing the benefits under, or
the administration of, the Plan. In the event the Claim Administrator provides to the Employer
such an electronic file for the Employer's use, including, but not limited to the Employer's
posting of such documents on the intranet and/or internet, the Employer acknowledges and
agrees that such electronic file is not intended to meet the Employer's requirements for
compliance under ERISA.
The Employer further acknowledges and agrees that it is solely responsible for providing
employees access, via the intranet, internet, or otherwise, to the most current version of any
electronic file provided to the Employer by the Claim Administrator at the Employer's request. In
addition, in all instances, the electronic file of the most current document issued to the Employer
by the Claim Administrator for use by the Employer is the legal document used to administer the
HCSC TX ASA Rev. 9/06
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Employer's Plan and will prevail in the event of any conflict between such electronic file and any
other electronic or paper file. The Employer is solely responsible for any and all claims for loss,
liability or damages, arising either directly or indirectly from the use or posting of the electronic
file on the intranet and/or internet.
XII. APPLICABLE LAW
This Agreement shall be governed by, and shall be construed in accordance with, the laws of
the state of Texas without regard to any state choice—of—law statutes, and any applicable
federal law. All disputes arising out of this Agreement will be resolved in Texas.
XIII. ENTIRE AGREEMENT
This Agreement, including all Exhibits and Addenda, represents the entire agreement and
understandings of the parties hereto and all prior agreements, understandings, representations
and warranties, whether written or oral, in regard to the subject matter hereof, including any
proposal document submitted by the Claim Administrator to the Employer pursuant to this
Agreement, are and have been merged herein to the extent applicable. In the event of a conflict,
the provisions of this Agreement and the Exhibits and Addenda of this Agreement shall prevail.
The Exhibits and Addenda of this Agreement as of the Agreement's effective date are:
• Exhibit I - Claim Administrator Services
• Exhibit II - Fee Schedule, Financial Responsibilities & Required Disclosures
• Exhibit III - Network Discount Guarantee Summary
• Exhibit IV — Performance Guarantee Agreement
This Agreement may be amended or altered in any of its provisions, including the addition or
deletion of any Exhibits and/or Addenda as provided herein, by the parties hereto and any such
change shall become effective when reduced to writing and signed by an authorized
representative of the parties or at such time as said amendment may provide.
XIV. NOTICE AND SATISFACTION
Unless specifically stated otherwise in this Agreement, the Employer and the Claim
Administrator agree to give one another written notice (pursuant to Section XVIII. Notices below)
of any complaint or concern the other party may have about the performance of obligations
under this Agreement and to allow the notified party thirty (30) days in which to make necessary
adjustments or corrections to satisfy the complaint or concern prior to taking any further action
with regard to such.
XV. LIMITATION OF LIABILITY
Liability for any errors or omissions by the Claim Administrator (or its officers, directors,
employees, agents or independent contractors) in the administration of this Agreement, or in the
performance of any duty or responsibility contemplated by this Agreement, shall be limited to
the maximum benefits which should have been paid under this Agreement had the errors or
omissions not occurred (including the Claim Administrator's share of any arbitration expenses
incurred, unless any such errors or omissions are adjudged to be the result of intentional
misconduct, gross negligence or intentional breach of a duty under this Agreement by the Claim
Administrator.
XVI. INSURANCE
Claim Administrator shall submit the Employer proof of insurance containing coverage for the
following:
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
General Liability Insurance per occurrence $1,000,000.00
General aggregate
Products-Comp/Op AGG
Personal & Adv. Injury
Professional Liability Insurance $1,000,000.00
Auto Liability Insurance (Any auto) $ 300,000.00
Worker's Compensation and Employers Liability Insurance:
Claim Administrator shall elect to obtain workers' compensation coverage pursuant to Section
406.002 of the Texas Labor Code. Further, Claim Administrator shall maintain said coverage
throughout the term of this Agreement, and shall comply with all provisions of Title 5 of the
Texas Labor Code to ensure that the Claim Administrator maintains said coverage. Any
termination of workers' compensation insurance coverage by Claim Administrator or any
cancellation or non -renewal of workers' compensation insurance coverage for the Claim
Administrator shall be a material breach of this Agreement. The Claim Administrator may
maintain Occupational Accident and Disability Insurance in lieu of Workers' Compensation
Employer's Liability with limits of at least $500,000.00 each accident, $500,000.00 by disease
policy limit, and $500,000.00 by disease each employee shall also be obtained and maintained
throughout the term of this Agreement.
Upon award of the Agreement to the Claim Administrator, the Claim Administrator shall submit a
certificate of insurance.
XVII. DISPUTE RESOLUTION
Any dispute arising out of or relating to this Agreement shall be resolved in accordance with the
procedures specified in this Section XVII., which shall be the sole and exclusive procedures for
the resolution of any such disputes. All negotiations pursuant to this Section XVII. are
confidential and shall be treated as compromise and settlement negotiations for purposes of
applicable rules of evidence, except where disclosure thereof is required by law.
A. Arbitration
In the event the parties fail to agree with respect to any matter covered herein, the question
in dispute shall be submitted for arbitration in Texas. The arbitrator shall be selected as
follows:
1. Upon declaration by one of the parties hereto that a deadlock exists, the parties shall
by agreement select an arbitrator;
2. If no appointment is made within thirty (30) days after the deadlock is declared and the
amount in contest is in excess of $200, the American Arbitration Association shall
recommend an arbitrator; or
3. If no appointment is made within thirty (30) days after the deadlock is declared and the
amount in question is $200 or less, the Claim Administrator shall select an independent
third party to be the arbitrator.
The arbitrator will submit a decision within thirty (30) days after appointment or as soon as
reasonably feasible and such decision shall be binding on the parties hereto. Arbitration
expenses will be shared equally by the parties. All other expenses (legal, incidental, etc.)
shall be borne by the losing party or, if both parties prevail, be apportioned by the arbitrator
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
to each party. Arbitration proceedings will be governed by the Rules of the American
Arbitration Association then in effect.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
B. Obligation to Continue Performance
Except as provided otherwise in this Agreement, each party is required to continue to per-
form its obligations under this Agreement pending final resolution of any dispute arising out
of or relating to this Agreement.
XVIII. NOTICES
All notices given under this Agreement must be in writing and shall be deemed to have been
given for all purposes when personally delivered and received or when deposited in the United
States mail, first—class postage prepaid, and addressed to the parties at their respective
addresses or when transmitted by facsimile via their respective facsimile numbers as indicated
in the most current Fee Schedule specifications of Exhibit II of this Agreement.
Each party may change such notice mailing and/or transmission information upon Timely prior
written notification to the other party.
XIX. SEVERABILITY
Should any provision(s) contained in this Agreement be held to be invalid, illegal, or otherwise
unenforceable, the remaining provisions of the Agreement shall be construed in their entirety as
if separate and apart from the invalid, illegal or unenforceable provision(s) unless such
construction were to materially change the terms and conditions of this Agreement.
XX. ENFORCEMENT
Any delay or inconsistency in the enforcement of any part of this Agreement shall not constitute
a waiver of any rights with respect to the enforcement of this Agreement at any future date nor
shall it limit any remedies which may be sought in any action to enforce any provision of this
Agreement.
XXI. FORCE MAJEURE
Neither party shall be liable for any failure to Timely perform its obligations under this
Agreement if prevented from doing so by a cause or causes beyond its commercially
reasonable control including, but not limited to, acts of God or nature, fires, floods, storms,
earthquakes, riots, strikes, wars or restraints of government.
XXII. NOTICE OF ANNUAL MEETING
The Employer is hereby notified that it is a Member of Health Care Service Corporation (HCSC),
a Mutual Legal Reserve Company, and is entitled to vote either in person, by its designated
representative, or by proxy at all meetings of Members of said Company. The annual meeting is
held at its principal office at 300 East Randolph Street, Chicago, Illinois each year on the last
Tuesday in October at 12:30 P.M.
For purposes of this Agreement, the term "Member" means the group, trust, association or other
entity with which this Agreement has been entered. It does not include Covered Employees or
Covered Persons under the Plan.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
The Effective Date of this Agreement is January 1, 2007.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date and year
first above written.
Date: October 26, 2006
CITY OF LUBBOCK
DAVID A. MILER, Mayor
Attest:
REBECCA GARZA, City SecrE6y
As -to Su nce:
s
LEISA HUTCHESON, Risk Manager
Assistant City Attorney
HCSC TX ASA Rev. 9./06
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Date: /D _/IPJD (;:P
BLUE CROSS AND BLUE SHIELD
OF TEXAS, a Division of Health Care
Service Corporation, a Mutual Legal
Reserve Company
THERESA A. CALDERON, Local Underwriting,
Texas Divisional Vice President
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
EXHIBIT I
CLAIM ADMINISTRATOR SERVICES
• CLAIMS ADJUDICATION
Examination of Claims and determination of payment levels, including data entry of Claims by
Claims departments, maintenance of Claims experience files, use of medical and/or dental
consultants, review of utilization and allowable amounts and Coordination of Benefits (COB).
• EXPLANATION OF BENEFITS (EOB)
Preparation and mailing of EOB forms.
• CLAIMS/MEMBERSHIP INQUIRIES
Handling of inquiries — written, phone or in—person — related to membership, benefits, and Claim
Payment or denial.
• ENROLLMENT SERVICE
Upon Employer request, assist Employer, in accordance with Claim Administrator's standard
procedures, in initial enrollment activities, including education of Covered Persons about benefits,
the enrollment process, selection of health care providers and how to file a Claim for benefits;
issue Claim submission instructions on behalf of Employer to health care providers who render
services to Covered Persons.
• CLIENT SERVICES AND MATERIALS
Provision of those items as elected by Employer from listing below:
a. Enrollment Materials. Implementation materials to be provided by Claim Administrator's
Marketing Administration Division during the enrollment process; any custom designed
materials may be subject to Supplemental Charge.
b. Standard Identification Cards. Provision of identification cards appropriate to health benefit
Plan coverage(s) selected.
c. Standard Provider Directories. Access to Network Provider directories and periodic updates
to such, if applicable to the health benefit Plan coverage(s) under the Agreement.
d. Customer Service. Access to toll—free customer service telephone number.
e. Medical Pre—authorization Helpline. For those services determined by Employer and
provided in writing to Claim Administrator that require pre—authorization, advance Claim
Administrator review of medical necessity of such services covered under the Plan; access to
toll—free medical pre—authorization helpline for Covered Persons and their health care
providers to call for assistance.
MEMBERSHIP VALIDATION
Verification of membership by wire, listing, electronic on—line query or other method prior to or
during adjudication.
MEMBERSHIP FILE UPDATES
Maintenance of membership status files, processing of inter—plan transfers and processing of
contract changes.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
OTHER MEMBERSHIP SERVICES
Contact Employer and/or Covered Employees regarding adding, changing or renewing coverage.
STANDARD REPORTS
Make available Claim data, Claim Settlement statements (as outlined in Exhibit II, Section III.D.)
and periodic reports in Claim Administrator's standard format(s) in accordance with Claim
Administrator's standard reporting policy, including quarterly claim file reports as mutually agreed
upon by the parties.
STOP LOSS COORDINATION
Coordinate all necessary reporting, tracking, notification and other similar financial and/or
administrative services pursuant to settlements under stop loss policy(ies) purchased from Claim
Administrator in conjunction with the Agreement. For stop loss coverage purchased from entity(ies)
other than Claim Administrator, such coordination is limited to this Exhibit's STANDARD
REPORTS to be made available to Employer subject to the Agreement's disclosure requirements.
• REPORTING SERVICES
Preparation and filing of annual Internal Revenue Service (IRS) 1099 forms for the reporting of
payments to health care providers who render services to Covered Persons and who are
reimbursed by the Plan for those services.
• ACTUARIAL AND STATISTICAL
Determination of claims projections and pricing of administrative services and stop—loss coverage.
• FINANCIAL SERVICES
Financial functions such as cash receipts, cash disbursements, payroll and general ledger
processing, general accounting, preparation of financial statements, billing, group settlement and
wire transfers.
• FRAUD DETECTION AND PREVENTION
Identify and investigate suspected fraudulent activity by Providers and/or Covered Persons and
inform Employer of findings and proof of fraud; address any related recovery litigation as set forth
in Exhibit III of the Agreement.
• BLUE ACCESS FOR EMPLOYERS
Provides Employer on—line access to conduct a variety of secure membership, enrollment,
reporting, administrative and billing transactions faster, more accurately and in real—time.
• BLUE ACCESS FOR MEMBERS
An on—line resource for personalized information about a Covered Person's health care coverage,
including, but not limited to, Claims status, email notification when a Claim has been finalized,
access to health and wellness information from Mayo Clinic, verification of dependents covered on
their plan and health risk assessment and such other services as become available.
• PROVIDER NETWORK(S)
If applicable to the health benefit Plan coverage(s) under the Agreement, establish, arrange and
maintain a Network(s) through contractual arrangements with Providers within the designated
service area(s).
• CERTIFICATE OF CREDITABLE COVERAGE
At the direction of Employer, issuance of Certificates of Creditable Coverage.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
BLUE CARE® CONNECTION
Full Blue Care Connection is an integrated, member -centric, approach to medical management.
The program includes Disease Management (with programs for Asthma, Diabetes, Congestive
Heart Failure and Coronary Artery Disease), Special Beginnings, 24 -Hour Nurse Line, Preventive
Care Initiatives and Predictive Modeling with Intense Case Management.
ADDITIONAL SERVICES NOT SPECIFIED
Claim Administrator may provide additional services not specified in the Agreement; such services
will be mutually agreed upon between the parties in writing prior to their performance and may be
subject to Supplemental Charge.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
EXHIBIT II
FEE SCHEDULE, FINANCIAL RESPONSIBILITIES,
AND REQUIRED DISCLOSURES
FEE SCHEDULE
Service charges and other Fee Schedule specifications in this Section I. are to apply for the
period(s) of time indicated herein and shall continue in full force and effect until the earlier of: i)
the end of the Fee Schedule Period noted below; ii) the date this Section I. Fee Schedule is
amended or replaced in its entirety; and iii) the date the Agreement is terminated.
A. FEE SCHEDULE PERIOD
Fee Schedule specifications in this Section I. are for the Fee Schedule Period indicated
below.
B. EMPLOYER GROUP NUMBER(S)
For the Fee Schedule Period noted above, the Agreement shall apply to the following
Employer Group Number(s): To Be Determined ("TBD").
C. ADMINISTRATIVE CHARGES AND CREDITS
1. The Administrative Charge, calculated monthly, shall be equal to the sum of the
amounts obtained by multiplying the total number of Covered Employees by category
by the appropriate factors shown below.
Fee Schedule Period commencing January 1, 2007 and ending on end of day,
December 31, 2007.
Per Covered Employee
Composite (for individual & family coverage)
Base Medical Administrative
Charge
$25.98
Blue Care Connection
$2.20
Cost Containment
$1.95
Total:
$30.13
Medical Dental
$30.13 $2.95 For each Covered Employee (individual/family composite)
Fee Schedule Period commencing January 1, 2008 and ending on end of day,
December 31, 2008.
HCSC TX ASA Rev. 9/06
Per Covered Employee
Composite (for individual & family coverage)
Base Medical Administrative
Charge
$30.54
Blue Care Connection
$2.20
Cost Containment
$1.95
Total:
$34.69
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Medical Dental
$34.69 $3.63 For each Covered Employee (individual/family composite)
Fee Schedule Period commencing January 1, 2009 and ending on end of day,
December 31, 2009.
Per Covered Employee
Composite (for individual & family coverage)
Base Medical Administrative
Charge
$32.62
Blue Care Connection
$2.20
Cost Containment
$1.95
Total:
$36.77
Medical Dental
$36.77 $3.85 For each Covered Employee (individual/family composite)
The Administrative Charges for the periods beginning January 1, 2008 and January 1,
2009 are contingent upon BCBSTX being the administrator for all medical coverage,
the enrollment not changing by more than 10%, the benefit design remaining in place,
and no necessary mandated legislative adjustments being imposed.
2. The Termination Administrative Charge shall be equal to the sum of the amounts
obtained by multiplying the total number of Covered Employees by category during the
three (3) months immediately preceding the date of termination by the appropriate
factors shown below.
Fee Schedule Period commencing January 1, 2007 and ending on end of day,
December 31, 2007.
Medical Dental
$13.00 $2.09 For each Covered Employee (individual/family composite)
Fee Schedule Period commencing January 1, 2008 and ending on end of day,
December 31, 2008 and Fee Schedule Period commencing January 1, 2009 and
ending on end of day, December 31, 2009.
To be determined
D. REPORTS
The Claim Administrator will make available to the Employer Standard Reports and other
Reporting Services as set forth in Exhibit I - CLAIM ADMINISTRATOR SERVICES of the
Agreement in accordance with its standard reporting policy at no additional charge. Any
additional reports required by the Employer must be mutually agreed upon by the parties in
writing prior to their development and may be subject to a Supplemental Charge.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
E. CHARGES FOR ADDITIONAL SERVICES
The following Additional Services shall be furnished:
Reimbursement: 25% of any recovered amounts*
*The indicated Reimbursement fee is based on the net recovery after attorney's fees, if
any, have been paid.
BlueCard® Program/Network access fees available upon request.
F. PLAN DESIGN MATERIALS
Benefit Booklets:
® No additional charge
Accept/Decline
❑ ® Customized ID Cards
❑ No additional charge
® ❑ Benefit Booklets
®
No additional charge
® No additional charge
❑
Supplemental Billing*
❑ ® Customized Benefit Booklets
❑
No additional charge
❑ Supplemental Billing`
❑
Supplemental Billing*
❑ ® Customized Covers
❑
No additional charge
Yes ® No ❑
❑
Supplemental Billing*
Subscriber Identification (ID) Cards:
Accept/Decline
® ❑ Subscriber ID Cards
® No additional charge
❑ Supplemental Billing*
❑ ® Customized ID Cards
❑ No additional charge
❑ Supplemental Billing*
Network Provider Directories
® No additional charge
❑ Supplemental Billing'
Claim Forms, Application Forms, Enrollment Materials
® No additional charge
❑ Supplemental Billing`
Special Mailings:
Cost has been included in Administrative Charge:
Yes ® No ❑
Identification Cards mailed to home addresses
Yes ® No ❑
Provider Directories mailed to home addresses
Yes ❑ No
*Any customized materials or additional services or supplies not documented in this Fee
Schedule may be subject to Supplemental Billing upon mutual agreement of the parties.
G. TRANSFER PAYMENT PERIOD
The Transfer Payment Period by which payments under Section III.C. of this Exhibit are to
be made is weekly.
H. CLAIM SETTLEMENT PERIOD
The Claim Settlement Period by which settlements under Section III.D. of this Exhibit are
to be made is monthly.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
I. RUN—OFF PERIOD
The Run—Off Period immediately following termination of the Agreement during which the
Claim Administrator will accept Run—Off Claims submitted for payment is twelve -(12)
months.
J. PLAN COVERAGE
Coverage under the Employer's Plan includes the following:
• Managed Health Care Coverage
• Comprehensive Dental Care coverage
K. NOTICE MAILING AND TRANSMISSION INFORMATION
Each party's address and facsimile number for the issuance of notices in accordance with
Section XVII. of the Agreement are shown below.
If to the Claim Administrator:
Blue Cross and Blue Shield of Texas,
a Division of Health Care Service Corporation
a Mutual Legal Reserve Company
901 South Central Expressway
Richardson, Texas 75080
Attention: Janet Pennington
Fax: 972-789-0224
If to the Employer:
City of Lubbock
1625 13th Street
Lubbock, Texas 79457
Attention: Leisa Hutcheson
Fax: 806-775-3316
With copy to:
City Attorney's Office
City of Lubbock
162513 th Street
Lubbock,Texas 79457
Fax: 806-775-3307
II. EXHIBIT DEFINITIONS
Other definitions applicable to this Exhibit are contained in Section ll. AGREEMENT
DEFINITIONS of the Agreement.
"Copayment" means a specified dollar amount that a Covered Person is required to pay
toward a Covered Service.
"Coshare" means a percentage of an eligible expense that a Covered Person is required to
pay toward a Covered Service.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
"Medicare Secondary Payer ("MSP")" means those provisions of the Social Security Act set
forth in 42 U.S.C. w1395 y (b), and the implementing regulations set forth in 42 C.F.R. Part 411,
as amended, which regulate the manner in which certain employers may offer group health care
coverage to Medicare—eligible employees, their spouses and, in some cases, dependent
children. (See Section IV.D. of this Exhibit titled "MEDICARE SECONDARY PAYER ("MSP")
DATA MATCH.")
"Run—Off Claim" means a Claim incurred prior to the termination of the Agreement that is
submitted for payment during the Run—Off Period.
"Run—Off Period" means the time period immediately following termination of the Agreement,
as specified in the most current Fee Schedule specifications of this Exhibit, during which the
Claim Administrator will accept Run—Off Claims submitted for payment.
"Termination Administrative Charge" means the consideration that is required by the Claim
Administrator upon termination of the Agreement, notwithstanding any services that may be
performed by the Claim Administrator during the Run—Off Period.
"Transfer Payment" means a payment in the amount outlined in Section III.C. of this Exhibit,
via wire, draft, electronic fund transfer (EFT) or such other method as mutually agreed to by the
parties in writing.
III. FINANCIAL RESPONSIBILITIES
A. COMPENSATION TO CLAIM ADMINISTRATOR
The Employer will pay service charges to the Claim Administrator, in accordance with the
most current Fee Schedule specifications of Section I. of this Exhibit. Unless otherwise
provided in this Agreement, such Fee Schedule specifications represent the sole
compensation to Claim Administrator for the processing of Claims and administrative and
other services provided to the Employer.
1. The service charges, which are guaranteed for the Fee Schedule Period indicated in
the most current Fee Schedule specifications of Section I. of this Exhibit, have been
determined in accordance with the Claim Administrator's current regulatory status and
the Employer's existing benefit program.
The service charges shall be subject to change by the Claim Administrator as follows:
a. At the end of the Fee Schedule Period indicated in the most current Fee Schedule
specifications of Section I. of this Exhibit, provided that sixty (60) days prior written
notice is given by the Claim Administrator;
b. On the effective date of any changes or benefit variances in the Plan, its
administration, or the level of benefit valuation which would increase the Claim
Administrator's cost of administration;
c. On any date changes imposed by governmental entities increase expenses
incurred by the Claim Administrator, provided that such increases shall be limited
to an amount sufficient to recover such increase in expenses;
d. On any date that the number of Covered Employees enrolled in the Plan changes
by an amount equal to ten percent (10%) or more of total enrollment over a one (1)
month period or twenty—five percent (25%) or more of total enrollment over a three
(3) month period; or
e. On any date an affiliate, subsidiary, or other business entity is added or dropped
by the Employer.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
2. In the event the Agreement is terminated in accordance with the "TERM AND
TERMINATION" provisions of the Agreement, the Employer will pay to the Claim
Administrator the Termination Administrative Charge indicated in the most current Fee
Schedule specifications of Section I. of this Exhibit ten (10) days before the date of
termination. This Termination Administrative Charge will be due and payable
regardless of whether or not the Claim Administrator processes and pays Run—Off
Claims during the Run—Off Period.
3. In addition to the amounts due and payable each month in accordance with the most
current Fee Schedule specifications of Section I. of this Exhibit, the Claim Administrator
may charge the Employer for:
a. Any applicable Supplemental Charge(s);
b. Reasonable fees for the reproduction or return of Claim records requested by the
Employer, a governmental agency or pursuant to a court order; and/or
c. Any other fees that may be assessed by third parties for services rendered to the
Employer and/or any other fees for services mutually agreed upon by the parties in
writing.
4. Administrative Charges will be paid based upon information the Claim Administrator
receives regarding current Plan enrollment as of the first day of each month.
Appropriate adjustments will be made for enrollment variances or corrections.
5. Performance of all duties and obligations of the Claim Administrator under the
Agreement are contingent upon the Timely payment of any amount owed the Claim
Administrator by the Employer.
B. CLAIM PAYMENTS
1. Upon receipt of a Claim, the Claim Administrator will make a Claim Payment provided
that all payments due the Claim Administrator under the terms of the Agreement are
paid when due.
2. Any reasonable determination by the Claim Administrator in adjudicating a Claim under
the Agreement that a Covered Person is entitled to a Claim Payment is conclusive
evidence of the liability of the Employer to the Claim Administrator for such Claim
Payment pursuant to Section III.D. below titled "CLAIM SETTLEMENTS."
3. If the Employer has failed to pay when due any amount owed the Claim Administrator,
the Claim Administrator shall be under no obligation to make any further Claim
Payments until such default is cured.
C. TRANSFER PAYMENT
In consideration of the Claim Administrator's obligations as set forth in the Agreement and
at the end of each Transfer Payment Period, the Employer shall transfer to the Claim
Administrator's account an amount equal to the Transfer Payment Period's Claim Payments
plus the applicable service charges. The Transfer Payment Period shall be as indicated in
the most current Fee Schedule specifications of Section I. of this Exhibit.
The Claim Administrator shall advise the Employer's Financial Division by email or facsimile
(at an email address or facsimile number to be furnished by the Employer prior to the
effective date of the Agreement) of the amount of Claim Payments pursuant to the
Agreement for which reimbursement has not been previously made by the Employer to the
Claim Administrator, plus the applicable service charges. Transfer Payment must be made
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
within twenty—four (24) hours of the Employer's notification by the Claim Administrator. If
any day on which a Transfer Payment is due is a holiday, such payment will be made on
the next business day. Late payments are subject to the penalties outlined in Section III.E.
of this Exhibit.
D. CLAIM SETTLEMENTS
1. A Claim Settlement shall be determined for each Claim Settlement Period indicated in
the most current Fee Schedule specifications of Section I. of this Exhibit. The Claim
Settlement shall reflect the sum of the following:
a. All Claim Payments paid by the Claim Administrator in the particular Claim
Settlement Period.
b. All Claim Payments paid by the Claim Administrator in prior Claim Settlement
Periods that have not been included in a prior Claim Settlement.
c. The Administrative Charges and Credits and other applicable service charges as
indicated in the most current Fee Schedule specifications of Section I. of this
Exhibit and any applicable Supplemental Charge(s).
The sum of a., b., and c. above shall be referred to as the Claim Settlement Total.
2. If, within the Claim Settlement Period, the Claim Settlement Total exceeds the Transfer
Payments, the Employer will pay the difference to the Claim Administrator. The Claim
Settlement will be determined within thirty (30) days from the last day of the Claim
Settlement Period. The Claim Administrator will notify the Employer in writing of the
results of the Claim Settlement. Any sums due the Claim Administrator will be paid
Timely by the Employer.
3. If, within the Claim Settlement Period, the Transfer Payments exceed the Claim
Settlement Total, the Claim Administrator may, at its option, pay such difference to the
Employer, apply the difference against amounts then owed the Claim Administrator by
the Employer or authorize a reduction equal to such difference from the next Claim
Settlement due the Claim Administrator from the Employer.
E. LATE PAYMENTS AND REMEDIES
1. If the Employer fails to pay when due any amount required to be paid to the Claim
Administrator under the Agreement, and such default is not cured within ten (10) days
of written notice to the Employer, the Claim Administrator may, at its option:
a. Suspend Claim Payments; or
b. Terminate the Agreement as of the effective date specified in such notice.
2. Pursuant to Section XX. "ENFORCEMENT' of the Agreement, the Claim
Administrator's failure to provide the Employer with timely notice of any amount due
hereunder shall not be considered a waiver of payment of any amount which may
otherwise be due hereunder from the Employer.
3. If the Employer fails to make any payment required by the Agreement on a Timely
basis, the Claim Administrator, at its option, may assess a daily charge for the late
remittance from the due date of any amount(s) payable to the Claim Administrator by
the Employer. This daily charge shall be an amount equal to the amount resulting from
multiplying the amount due times the lesser of:
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
IV
a. The rate of .0329% per day which equates to an amount of twelve percent (12%)
per annum; or
b. The maximum rate permitted by state law.
4. In addition, if the Employer becomes insolvent, however evidenced, or is in default of
its obligation to make any Transfer Payment as provided hereunder, or if any other
default hereunder has occurred and is continuing, then any indebtedness of the Claim
Administrator to the Employer (including any and all contractual obligations of the
Claim Administrator to the Employer) may be offset and/or recouped and applied
toward the payment of the Employer's obligations hereunder, whether or not such
obligations, or any part thereof, shall then be due the Employer.
F. FINANCIAL OBLIGATIONS UPON AGREEMENT TERMINATION
1. The Employer hereby acknowledges that on the date of termination of the Agreement
in accordance with the provisions of either Section III.E. of this Exhibit or Section VIII.
of the Agreement, there may be an undetermined but substantial number of Claims for
services rendered or furnished prior to that date which have not been submitted to the
Claim Administrator for reimbursement and also an undetermined but substantial
number of Claims submitted for reimbursement which have not been paid by the Claim
Administrator ("Run—Off Claims"). The Employer shall be responsible for the
reimbursement of all Run—Off Claims, whether or not such Claims have been
submitted, or whether or not Claim Payments for such Claims have been made by the
Claim Administrator, as of the date of termination, including, but not limited to, Claim
Payments made in accordance with MSP laws, and for the payment of the Termination
Administrative Charge and any other applicable service charges as indicated in the
most current Fee Schedule specifications of Section I. of this Exhibit and any
applicable Supplemental Charge(s) pursuant to the processing of such Claims after the
Agreement's termination date.
2. In consideration of the Claim Administrator's continuing to make Claim Payments in
accordance with Section III.B. of this Exhibit for Run—Off Claims, the Employer shall
continue to make Transfer Payments for all such Claims paid by the Claim
Administrator up to the Final Settlement outlined below.
3. A Final Settlement shall be made within sixty (60) days after the last day of the Run—
Off Period. This Final Settlement shall compare the Transfer Payments against the
Claim Settlement Totals for all Run—Off Claims paid up to the date of the Final
Settlement. The difference shall be paid or applied as set forth in Section III.D. of this
Exhibit. However, if the Transfer Payments exceed the Claim Settlement Totals for all
Run—Off Claims paid up to the Final Settlement, the Claim Administrator shall pay such
difference to the Employer after applying the difference against amounts, if any, then
owed to the Claim Administrator by the Employer.
REQUIRED DISCLOSURE PROVISIONS
The Employer represents that it acknowledges and has communicated the provisions stated in
this Section IV. to its Covered Persons.
A. PAYMENT OF CLAIMS AND ASSIGNMENT OF BENEFITS
1. All payments by the Claim Administrator for the benefit of any Covered Person may be
made directly to any Provider furnishing Covered Services for which such payment is
due, and the Claim Administrator is authorized by such Covered Person to make such
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
payments directly to such Providers. However, the Claim Administrator reserves the
right in its sole discretion to pay any benefits that are payable under the terms of the
Plan directly to the Covered Person or Provider furnishing Covered Services. All
benefits payable to the Covered Person which remain unpaid at the time of the death
of the Covered Person will be paid to the estate of the Covered Person.
2. Once Covered Services are rendered by a Provider, the Covered Person has no right
to request the Claim Administrator not to pay the Claim submitted by such Provider and
no such request by a Covered Person or his agent will be given effect. Furthermore,
the Claim Administrator will have no liability to the Covered Person or any other person
because of its rejection of such request.
3. Neither the Plan nor a Covered Person's claims for payment of benefits under the Plan
are assignable in whole or in part to any person or entity at any time. Coverage under
the Plan is expressly non—assignable or non—transferable and will be forfeited if a
Covered Person attempts to assign or transfer coverage or aids or attempts to aid any
other person in fraudulently obtaining coverage under the Plan. However, if the Claim
Administrator makes payment because of a person's wrongful use of the identification
card of a Covered Person, such payment will be considered a proper payment and the
Claim Administrator will have no obligation to pursue recovery of such payment.
B. COVERED PERSON/PROVIDER RELATIONSHIP
The choice of a Provider is solely the choice of the Covered Person and the Claim
Administrator will not interfere with the Covered Person's relationship with any Provider.
1. It is expressly understood that the Claim Administrator does not itself undertake to
furnish hospital, medical or dental service, but solely to make payment to a Provider for
the Covered Services received by Covered Persons. The Claim Administrator is not in
any event liable for any act or omission of any Provider or the agent or employee of
such Provider, including, but not limited to, the failure or refusal to render services to a
Covered Person. Professional services which can only be legally performed by a
Provider are not provided by the Claim Administrator. Any contractual relationship
between a Provider and the Claim Administrator shall not be construed to mean that
the Claim Administrator is providing professional service.
2. The use of an adjective such as Approved, Administrator, Participating, In -Network or
Network in modifying a Provider shall in no way be construed as a recommendation,
referral or any other statement as to the ability or quality of such Provider. In addition,
the omission, non-use or non -designation of Approved, Administrator, Participating, In -
Network, Network or any similar modifier or the use of a term such as Non -Approved,
Non -Administrator, Non -Participating, Out -of -Network or Non -Network should not be
construed as carrying any statement or inference, negative or positive, as to the skill or
quality of such Provider.
3. Each Provider provides Covered Services only to Covered Persons and does not deal
with or provide any services to the Employer (other than as an individual Covered
Person) or the Plan.
C. CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH
PROVIDERS
1. BlueCard
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Like all Blue Cross and Blue Shield Licensees, the Claim Administrator participates in a
program called "BlueCard." Whenever Covered Persons access health care services
outside the Claim Administrator's service area, the Claims for those services may be
processed through BlueCard and presented to the Claim Administrator for payment in
conformity with network access rules of the BlueCard Policies then in effect ("Policies").
Under BlueCard, when Covered Persons receive Covered Services within the
geographic area served by an on—site Blue Cross and/or Blue Shield Licensee ("Host
Blue"), the Claim Administrator will remain responsible to the Employer for fulfilling the
Claim Administrator's contract obligations.
However, the Host Blue will only be responsible, in accordance with applicable
BlueCard Policies, if any, for providing such services as contracting with its
participating Providers and handling all interaction with its participating Providers. The
financial terms of BlueCard are described generally below.
Liability Calculation Method Per Claim
The calculation of a Covered Person's liability on Claims for Covered Services incurred
outside the Claim Administrator's service area and processed through BlueCard will be
based on the lower of the Provider's billed charges or the negotiated price the Claim
Administrator pays the Host Blue.
The calculation of the Employer's liability on Claims for Covered Services incurred
outside the Claim Administrator's service area and processed through BlueCard will be
based on the negotiated price the Claim Administrator pays the Host Blue.
The methods employed by a Host Blue to determine a negotiated price will vary among
Host Blues based on the terms of each Host Blue's Provider contracts. The negotiated
price paid to a Host Blue by the Claim Administrator on a Claim for Covered Services
processed through BlueCard may represent:
(1) The actual price paid on the Claim by the Host Blue to the health care Provider
("Actual Price"), or
(2) An estimated price, determined by the Host Blue in accordance with BlueCard
Policies, based on the Actual Price increased or reduced to reflect aggregate
payments expected to result from settlements, withholds, any other contingent
payment arrangements and non—Claims transactions with all of the Host Blue's
health care Providers or one or more particular Providers ("Estimated Price"), or
(3) An average price, determined by the Host Blue in accordance with BlueCard
Policies, based on a billed charges discount representing the Host Blue's average
savings expected after settlements, withholds, any other contingent payment
arrangements and non—Claims transactions for all of its Providers or for a specified
group of Providers ("Average Price"). An Average Price may result in greater
variation to the Covered Person and the Employer from the Actual Price than
would an Estimated Price.
Host Blues using either the Estimated Price or Average Price will, in accordance with
BlueCard Policies, prospectively increase or reduce the Estimated Price or Average
Price to correct for over— or underestimation of past prices. However, the amount paid
by the Covered Person and the Employer is a final price and will not be affected by
such prospective adjustment. In addition, the use of a liability calculation method of
Estimated Price or Average Price may result in some portion of the amount paid by the
Employer being held in a variance account by the Host Blue, pending settlement with
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
its participating Providers. Because all amounts paid are final, the funds held in a
variance account, if any, do not belong to the Employer and are eventually exhausted
by Provider settlements and through prospective adjustments to the negotiated prices.
Statutes in a small number of states may require a Host Blue either a) to use a basis
for calculating a Covered Person's liability for Covered Services that does not reflect
the entire savings realized, or expected to be realized, on a particular Claim or b) to
add a surcharge. Should any state statutes mandate liability calculation methods that
differ from the negotiated price methodology or require a surcharge, the Claim
Administrator would then calculate the Covered Person's liability and the Employer's
liability for any Covered Services consistent with the applicable state statute in effect at
the time the Covered Person received those services.
Return of Overpayments
Under BlueCard, recoveries from a Host Blue or from participating Providers of a Host
Blue can arise in several ways, including, but not limited to, anti—fraud and abuse
audits, Provider/hospital audits, credit balance audits, utilization review refunds, and
unsolicited refunds. In some cases, the Host Blue will engage third parties to assist in
discovery or collection of recovery amounts. The fees of such a third party are netted
against the recovery. Recovery amounts, net of fees, if any, will be applied in
accordance with applicable BlueCard Policies, which generally require correction on a
Claim—by—Claim or prospective basis.
BlueCard Fees and Compensation
The Employer understands and agrees a) to pay certain fees and compensation to the
Claim Administrator which the Claim Administrator is obligated under BlueCard to pay
to the Host Blue, to the Blue Cross and Blue Shield Association, or to the BlueCard
vendors and b) that fees and compensation under BlueCard may be revised from time
to time without the Employer's prior approval in accordance with the standard
procedures for revising fees and compensation under BlueCard. Some of these fees
and compensation are charged each time a Claim is processed through BlueCard and
include, but are not limited to, access fees, administrative expense allowance fees,
Central Financial Agency Fees, and ITS Transaction Fees. Also, some of these Claim—
based fees, such as the access fee and the administrative expense allowance fee, may
be passed on to the Employer as an additional Claim liability. Other fees include, but
are not limited to, a toll—free phone number fee and a fee for providing certain Provider
directories. If you do not have a complete listing, or want an updated listing, of these
types of fees or the amount of these fees paid directly by the Employer, you should
contact the Claim Administrator's representative.
2. Servicing Plan Agreements between Claim Administrator and Other Blue Cross
and Blue Shield Plans
In some instances, the Claim Administrator has entered into agreements with other
Blue Cross and Blue Shield Plans (hereinafter called the "Servicing Plans") to provide,
on the Claim Administrator's behalf, Claim Payments and certain administrative
services for those Covered Persons of the Employer residing in the state and/or
service area of the Servicing Plans. Pursuant to the agreement between the Claim
Administrator and the Servicing Plans, the Claim Administrator has agreed to
reimburse each Servicing Plan for all Claim Payments made on the Claim
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
Administrator's behalf for those Covered Persons of the Employer residing in the state
and/or service area of such Servicing Plan.
The Claim Administrator hereby informs the Employer, and the Employer shall advise
its Covered Persons, that certain Servicing Plans may have contracts with certain
Providers ("Servicing Plan Providers") in their service area for the provision of, and
payment for, health care services to persons entitled to health care benefits under
health policies and contracts to which the Servicing Plan is a party, including the
Covered Persons covered under the Administrative Services Agreement, and that
pursuant to the Servicing Plan's contracts with its Servicing Plan Providers, under
certain circumstances described therein, the Servicing Plan may receive substantial
payment from Servicing Plan Providers with respect to services rendered to such
persons for which the Servicing Plan was obligated to pay the Servicing Plan Provider,
or the Servicing Plan may pay Servicing Plan Providers less than their billed charges
for services, by discounts or otherwise, or may receive from Servicing Plan Providers
other allowances under the Servicing Plan's contracts with them. The Employer
acknowledges that in negotiating the service charge set forth in the Agreement, it has
taken into consideration that, among other things, the Servicing Plan may receive such
payments, discounts and/or other allowances during the term of its agreement with the
Claim Administrator. Further, all amounts payable to the Servicing Plan by the Claim
Administrator for Claim Payments made by the Servicing Plan and applicable service
charges thereon pursuant to the terms of its agreement with the Claim Administrator
(and with respect to most Servicing Plans, any required deductible and Coshare
amounts under the Employer's Plan) shall be calculated on the basis of the Servicing
Plan Provider's Claim Charge for Covered Services rendered to a Covered Person,
irrespective of any separate financial arrangement between the Servicing Plan Provider
and the Servicing Plan as referred to herein. However, the Employer acknowledges
that the Claim Administrator, under its contract with each Servicing Plan, may be
required to reimburse the Servicing Plan only for Claim Payments which have been
discounted pursuant to an agreement between the particular Servicing Plan and its
Servicing Plan Providers including the service charges thereon. In any event the
Employer shall reimburse the Claim Administrator the amount paid by the Claim
Administrator to the Servicing Plan for Claim Payments plus any service charges
payable by the Claim Administrator to the Servicing Plan, in addition to applicable
service charges of the Claim Administrator hereunder.
The Claim Administrator hereby informs the Employer, and the Employer acknowledges,
that the Claim Administrator's, the Host Plans' and the Servicing Plans' Provider contracting
arrangements, operational practices and procedures, and the policies and procedures
governing software used to process Claims for services rendered by the Claim
Administrator's Providers, Host Plans' Providers and the Servicing Plans' Providers may
result in minor deviations in Claim processing and/or pricing of Claims for same services.
D. MEDICARE SECONDARY PAYER ("MSP") DATA MATCH
In an effort to facilitate the processing of Claims consistent with the requirements of the
MSP statute, and to assist in meeting the statutory obligations, certain Blue Cross and Blue
Shield Plans together with the Centers for Medicare & Medicaid Services ("CMS"), formerly
known as Health Care Financing Administration ("HCFA"), the federal government agency
which administers Medicare, have developed a new enrollment and membership system.
The system, also referred to as the "Data Match," is aimed at obtaining, in a Timely and
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
current fashion, information necessary for the Claim Administrator to identify dual coverage
situations which fall within the MSP statute, and to determine whether primary or secondary
payment should be made for a particular Claim.
Under the system, the Claim Administrator will provide basic information to CMS about
individuals enrolled in Group Health Plans who are also covered by Medicare so that CMS
can better detect dual coverage situations.
The Employer hereby authorizes and directs the Claim Administrator to disclose to CMS
periodically, information pertaining to Medicare—eligible Covered Persons under the Plan.
The Employer agrees that the Claim Administrator's ability to make accurate
primary/secondary MSP determinations depends on the breadth and accuracy of the Claim
Administrator's files concerning Covered Persons. The Employer agrees to use best efforts
in responding promptly and accurately to the Claim Administrator's requests for information
and to require and facilitate its Covered Persons' cooperation in responding promptly and
accurately to such requests.
Further, to assure the continuing accuracy of the Claim Administrator's files, the Employer
agrees that it is the Employer's responsibility to notify the Claim Administrator promptly of
any change in the size of the Employer's work force or status of its employees that might
affect the order of payment under the MSP statute, such as information regarding working—
aged persons who retire and changes in the size of the Employer's work force that place it
in, or take it out of, the scope of the MSP statute. If the Claim Administrator does not
receive such information from the Employer, the Claim Administrator will assume that all
relevant factors remain unchanged and will process Claims accordingly. The group
acknowledges and agrees that the Claim Administrator will be using the information
provided by the Employer and Covered Persons to update the Claim Administrator's files,
and will also forward this information to CMS so that CMS can revise its file to reflect
relevant changes in primary/secondary status.
The Claim Administrator may, in its sole discretion, discontinue its participation in the Data
Match system as described above. Nothing in the Agreement shall be construed as
obligating the Claim Administrator to continue its participation in the Data Match system.
Disclosure Statement: The Employer acknowledges that the Claim Administrator has
furnished it with a copy of a pamphlet entitled "Information Regarding the Medicare
Secondary Payer Statute" (also referred to as the "Disclosure Statement"), prepared by the
Blue Cross and Blue Shield Association and reviewed by CMS, which administers
Medicare.
E. REIMBURSEMENT PROVISION
If a Covered Person incurs expenses for sickness or injury that occurred due to the
negligence of a third party and benefits are provided for Covered Services described in the
Plan, the following provisions will apply:
1. The Claim Administrator on behalf of the Employer has the right to reimbursement for
all benefits the Claim Administrator provided from any and all damages collected from
the third party for those same expenses whether by action at law, settlement, or
compromise, by the Covered Person, the Covered Person's parents, if the Covered
Person is a minor, or the Covered Person's legal representative as a result of that
sickness or injury, in the amount of the Provider's Eligible Charge for Covered Services
for which the Claim Administrator has provided benefits to the Covered Person.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
2. The Claim Administrator is assigned the right to recover from the third party, or his or
her insurer, to the extent of the benefits the Claim Administrator provided for that
sickness or injury.
The Claim Administrator shall have the right to first reimbursement out of all funds the
Covered Person, the Covered Person's parents, if the Covered Person is a minor, or the
Covered Person's legal representative is or was able to obtain for the same expenses for
which the Claim Administrator has provided benefits as a result of that sickness or injury.
The Covered Person is required to furnish any information or assistance or provide any
documents that the Claim Administrator may reasonably require in order to obtain its rights
under this provision. This provision applies whether or not the third party admits liability.
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
EXHIBIT III
CITY OF LUBBOCK
NETWORK DISCOUNT GUARANTEE
EFFECTIVE JANUARY 1, 2007
A. PARTICIPATING PLANS
Participating
Total
Participation
Savings %
Plans
Participation
% of Total
by BC Plan
Alabama
0
0.00%
56.12%
Arizona
1
0.04%
57.84%
Arkansas
1
0.04%
44.35%
California Cross (Wellpoint)
0
0.00%
55.05%
California Shield
0
0.00%
51.68%
Colorado (Wellpoint)
0
0.00%
47.52%
Connecticut (Wellpoint)
0
0.00%
46.81%
Delaware (Carefirst)
0
0.00%
39.41%
District of Columbia (Carefirst)
0
0.00%
50.67%
Florida
0
0.00%
58.75%
Georgia (Wellpoint)
0
0.00%
46.27%
Hawaii
0
0.00%
51.28%
Idaho Cross
0
0.00%
25.94%
Idaho Shield (Regence)
0
0.00%
18.35%
Illinois (HCSC)
0
0.00%
50.71%
Indiana (Wellpoint)
0
0.00%
43.03%
Iowa (Wellmark)
0
0.00%
38.72%
Kansas
0
0.00%
42.32%
Kentucky (Wellpoint)
0
0.00%
49.74%
Louisiana
0
0.00%
53.48%
Maine (Wellpoint)
0
0.00%
24.65%
Maryland (Carefirst)
0
0.00%
28.42%
Massachusetts
0
0.00%
51.00%
Michigan
0
0.00%
49.22%
Minnesota
0
0.00%
31.63%
Mississippi
0
0.00%
46.55%
Missouri (Kansas City)
0
0.00%
39.73%
Missouri (Wellpoint (St. Louis))
1
0.04%
48.03%
Montana
0
0.00%
19.47%
Nebraska
0
0.00%
33.34%
Nevada (Wellpoint)
0
0.00%
56.16%
New Hampshire (Wellpoint)
0
0.00%
29.99%
New Jersey
0
0.00%
59.51%
New Mexico (HCSC)
1
0.04%
41.67%
New York (Central)
0
0.00%
41.47%
New York (Empire)
0
0.00%
56.43%
New York (Finger Lakes)
0
0.00%
35.87%
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Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies
and third party representatives, except under written agreement.
New York (Northeastern)
0
0.00%
46.63%
New York (Utica)
0
0.00%
39.17%
New York (Western)
0
0.00%
50.17%
North Carolina
0
0.00%
46.50%
North Dakota
0
0.00%
35.19%
Ohio (Wellpoint)
0
0.00%
49.13%
Oklahoma
0
0.00%
43.98%
Oregon (Regence)
0
0.00%
32.53%
Pennsylvania (Capital)
0
0.00%
44.35%
Pennsylvania (Highmark)
0
0.00%
54.66%
Pennsylvania (Independence)
0
0.00%
41.67%
Pennsylvania (Northeastern)
0
0.00%
31.20%
Puerto Rico (La Cruz Azul)
0
0.00%
0.00%
Puerto Rico (Triple S)
0
0.00%
20.30%
Rhode Island
0
0.00%
52.47%
South Carolina
1
0.04%
46.71%
South Dakota (Wellmark)
0
0.00%
33.38%
Tennessee
0
0.00%
50.78%
Texas (HCSC)
2,348
99.79%
52.01%
Utah (Regence)
0
0.00%
32.25%
Vermont
0
0.00%
22.99%
Virgin Islands
0
0.00%
3.93%
Virginia (Wellpoint)
0
0.00%
48.46%
Washington (Seattle - Regence)
0
0.00%
43.72%
Washington/Alaska (Premera)
0
0.00%
36.18%
West Virginia (Mountain State)
0
0.00%
29.83%
Wisconsin (Wellpoint)
0
0.00%
20.84%
Wyoming
0
0.00%
9.68%
Total
2,353
100.00%
52.00%
*Note: Target is subject to change based on actual average participation for each Plan during
the 2007 policy period.
B. TOTAL AMOUNT AT RISK
Total Amount at Risk:
$3.50 2,353 Current Enrollment
Est.
Annual $98,826
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C. PENALTY MATRIX
Total Amount at Risk* = $98,826
Actual
Discount
Target 52.0%
Risk Free
Corridor
49.0%
* Amount at Risk is based on current enrollment of 2,353 employees. Actual amount at
risk is subject to change based on final enrollment of employees who select BCBSTX
coverage.
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$19,765
Penalty
47.0%
46.9%
$39,530
Penalty
45.0%
44.9%
$59,296
Penalty
43.0%
42.9%
$79,061
Penalty
41.0%
40.9%
$98,826
Penalty
39.0% -
* Amount at Risk is based on current enrollment of 2,353 employees. Actual amount at
risk is subject to change based on final enrollment of employees who select BCBSTX
coverage.
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D. NETWORK DISCOUNT GUARANTEE SUMMARY
Risk Free Corridor: No Penalty for discounts within 3.0% of the Target Discount
Penalty: 20% of the total amount of risk for each band
Total amount at risk*: $98,826
Target for Overall Network Discount: 52.00%
1. BCBSTX reserves the right to re-evaluate and re-establish the Target Discount if
Medicare changes its payment systems during the term of this Network Discount
Guarantee.
2. Network Discount Guarantee applies only to eligible employees and retirees who
enroll the proposed BCBSTX benefit plans.
3. BCBSTX reserves the right to re-evaluate and re-establish the Target Discount if the
participation changes by more than plus or minus 10% or if the distribution of enrolled
employees between participating Plans changes significantly.
4. BCBSTX reserves the right to re-evaluate and re-establish the Target Discount if there
is a change in the benefit plan design.
5. BCBS will exclude all claims in excess of $175,000 from this Network Discount
Guarantee.
6. BCBSTX reserves the right to void this Network Discount Guarantee if there are less
than 2,118 employees enrolled in the plan.
7. Claims will exclude Medicare -related claims and claims with COB.
* Amount at Risk is based on current enrollment of 2,353 employees. Actual
amount at risk is subject to change based on final enrollment of employees who
select BCBSTX coverage.
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Resolution No. 2006-RO511
October 13, 2006
EXHIBIT IV Item No. 6.10
Blue Cross and Blue Shield of Texas
PPO Medical Performance Guarantees offered to
CITY OF LUBBOCK
Agreement Period January 1, 2007 through December 31, 2007
BCBSTX is pleased to offer the following standards on our performance. These guarantees will
only apply if we obtain and maintain a minimum of 1,800 employees enrolled in the BCBSTX
coverages indicated.
Performance guarantee measurement will begin the 4th month following the Group
effective date provided that conditions and requirements of the Administrative Services
Agreement are met.
Service
Definition
Level of
Percent
Performance
at Risk'
Claim
Turnaround time is defined as the number of
Turnaround
days it takes to process a claim, beginning with
90.0%-100%
0%
Time
the date the claim is received to the check/EOB
0%-89.9%
2%
date on participant filed claims or to the date the
claim passes all edits on provider filed claims.
The standard is measured as a percent of
process -ready claims2 finalized within 14 calendar
days on a group -specific basis.
Claim
Processing accuracy is defined as the percent of
95.0%-100%
0%
Processing
claims processed accurately. The level of
0%-94.9%
2%
Accuracy
performance is based on the results from a
random sample audit of all claims processed for
those customers assigned to the Unita.
Claim
Financial accuracy is defined as the percent of
97.0%-100%
0%
Financial
dollars paid accurately. The level of performance
0%-96.9%
2%
Accuracy
is based on the results from a random sample
audit of all claims processed for those customers
assigned to the Unita.
Inquiry
Inquiry resolution is defined as number of days it
Resolution
takes to resolve a participant inquiry, beginning
95.0%-100%
0%
with the date the inquiry is received to the
0%-94.9%
2%
resolution date. All written and telephone inquiries
will be measured. The standard is measured as a
percent processed within 14 calendar days on a
group -specific basis.
Abandoned
Abandoned calls are defined as calls, calculated
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Calls
over the complete workday, that reach the facility
0%-5.0%
0%
and are placed in a queue, but are not answered
5.1%-10%
1 %
because the caller hangs up before a service
10.1%-100%
2%
representative becomes available. Any calls
abandoned or terminated by the caller prior to the
Average Speed to Answer number of seconds
standard will not be counted as Abandoned Calls.
Standard is measured using participant calls on a
group -specific basis.
Average
Average Speed To Answer, calculated over the
Speed to
complete workday, is defined as the time a caller
0-30
0%
Answer
spends on hold until a service representative
seconds
1%
becomes available. Standard is measured by
31-60
2%
determining the average number of seconds the
seconds
caller spends waiting for a service representative.
61 seconds
Standard is measured using participant calls on a
or more
roup specific basis.
Total
12%
Notes:
1. Dollars at risk are based on the indicated percentage of base administrative charge. Base
administrative charges exclude commissions or broker's fees and cost containment
program fees.
2. Process -ready claims are defined as claims that contain all information required to process
the claim.
3. Unit is defined as the area responsible for processing the Group's claims.
4. Performance guarantees will be measured and settled on an annual basis.
PERFORMANCE GUARANTEES ADMINISTRATION
The Performance Guarantees described herein shall apply to the Administrative Services Agreement
(the Agreement) between Blue Cross and Blue Shield of Texas a Division of Health Care Service
Corporation, a Mutual Legal Reserve Company, (BCBSTX or Claim Administrator) and City of
Lubbock (Employer) to which this Addendum is attached and have the same force and effect as the
most current Fee Schedule, unless amended, replaced, or terminated by the parties to this Agreement
in writing.
The Performance Guarantees set out in this Addendum are limited solely to the medical benefit
coverage indicated in the most current Fee Schedule and do not include prescription drug, dental,
vision, health maintenance organization (HMO), life, accidental death and disability coverage, or
services, if applicable, under the medical management programs provided by Claim Administrator when
elected by the Employer.
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All obligations, terms, conditions, promises, agreements, and language in the Administrative Services
Agreement and the most current Fee Schedule apply equally to the obligations, terms, conditions,
promises, agreements, and language in this Addendum PG and the most current Exhibit -PG.
SECTION I
DEFINITIONS
Abandoned Calls means all Calls that reach Claim Administrator and are placed in queue but
have not reached their final destination. The Call becomes an Abandoned Call when it is
terminated because the Caller intentionally ends the Call before a customer service
representative becomes available. Any Calls abandoned or terminated by the Caller prior to the
Average Speed to Answer number of seconds standard will not be counted as Abandoned
Calls.
Average Speed to Answer means the time the Caller spends on hold after being placed in
queue until a customer service representative becomes available.
Base Administrative Charge is the portion of the Administrative Charge identified in Section
I.C.1 of Exhibit II.
Call means a measurable telephone Call placed by a Caller.
Caller means a Covered Person, as defined under the Agreement.
Claim means notification acceptable to the Claim Administrator that a service has been
rendered or furnished to a covered person in accordance with the provisions of the health care
benefit program in effect on the date a service is rendered or furnished. This notification must
set forth in full the details of such service including, but not limited to, the covered person's
name, age, sex and identification number, the name and address of the provider of service, a
specific itemized statement of the service rendered or furnished, the date of service, applicable
diagnosis and the fee for such service.
Claim Financial Accuracy means the percent of dollars paid accurately in accordance with the
provisions of the medical benefit coverage administered by Claim Administrator.
Claim Payment means the benefit payment made by the Claim Administrator, upon submission
of a Claim, in accordance with the Employer's health care benefit program.
Claim Processing Accuracy means the accuracy rate achieved by the Claim Administrator in
adjudicating claims in accordance with the provisions of the medical benefit coverage
administered by Claim Administrator.
Claims Processing Turnaround Time means the period beginning on the date the Claim
Administrator or Host Blue receives a Claim for processing through the date the Claim passes
all system edits and benefits are approved or denied by the Claim Administrator.
Inquiry means a written or oral question that is submitted by a Covered Person to Claim
Administrator and actually received by a Claim Administrator employee charged with responding
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to such inquiries. Notwithstanding any other considerations, oral or written Inquiries may only
be actually received during Claim Administrator's normal business hours.
Inquiry Timeliness means response time to a Covered Person's Inquiry. An Inquiry is resolved
on the earlier of the date an oral response is communicated by Claim Administrator or the date
a written response is sent by Claim Administrator. If additional information is requested outside
of Claim Administrator or a professional review is required, the time from the date of the request
to the date the information is received will be carved out. Examples of additional information
include but are not limited to medical records that must be requested from a health care
provider, coordination or maintenance of benefits, or student verification inquiries.
Process -Ready Claim means a Claim that, when received by the Claim Administrator, contains
all of the Claim information required to process the Claim.
Settlement Period means the period for which the Claim Administrator's service performance
shall be evaluated. For purposes of this Agreement, the Settlement Period is indicated on the
most current Exhibit -PG.
Unit means the area responsible for claims processing and customer service for the Employer.
SECTION II
CALCULATION
A. Percentage levels of Claim Administrator's performance of administrative duties will be
calculated by taking the weighted average of the levels of performance during the
Settlement Period indicated on the most current Exhibit -PG.
B. All measurement and calculation methods used in determining performance results are
in accordance with the Blue Cross and Blue Shield Association performance reporting
guidelines and/or Claim Administrator corporate policies. Each standard is measured as
indicated in the most current Exhibit -PG, attached to and made a part of this Addendum
PG. Highlights of those guidelines are as follows:
Abandoned Call rate is measured by dividing the number of Abandoned Calls, as
defined, by the total number Calls accepted. Call totals are provided by telephone
reports that capture the number of Calls accepted and abandoned.
Average Speed of Answer will be calculated by dividing the total length of time for all
Calls, measured from the time a Call is queued by the automated telephone system for
the next available customer service representative until the time the Caller is connected
with a customer service representative, by the total number of Calls connected with a
customer service representative at the Claim Administrator's customer service unit
during the Settlement Period. The Average Speed to Answer is provided by telephone
reports that compute the average number of seconds that Callers spend on hold waiting
for their Call to be answered.
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Claim Financial Accuracy rate is determined from an audit of randomly selected
stratified claims. Claims are stratified by amount paid. Total dollars overpaid and total
dollars underpaid are projected over each stratum.
The Claim Financial Accuracy is computed by summing the projected overpayments and
the projected underpayments (absolute value) from each stratum and dividing by the
total population dollars that should have been paid, (total population dollars paid plus
projected underpayments minus projected overpayments). The end result is subtracted
from one for the accuracy rate. The results incorporate statistically valid samplings.
Claim Processing Accuracy rate is determined from the same stratified claims sample
used to determine Claim Financial Accuracy. A Claim Processing Accuracy percentage
is calculated for each stratum by dividing the number of accurately processed claims by
the number of claims selected in the stratum.
Each accuracy percentage is then weighted according to the total claim population. The
Claim Processing Accuracy rate is determined by combining the weighted accuracy for
each stratum.
Claim Processing Accuracy refers to Claims processed without processing errors such
as:
1. Coding - incorrect claim data entry.
2. Benefit Administration - failure to adhere to the Employer's health care benefit
program design.
3. Procedural Administration - failure to adhere to the administrative procedures.
4. System Administration - computer-generated errors, benefit programming errors,
calculation errors.
5. Excluding:
a. Any administrative inaccuracies that do not impact claims disposition—or
customer reporting;
b. Errors entered by providers of service;
c. Benefits provided to an ineligible claimant due to the Employer's failure to
provide timely and accurate eligibility information to the Claim Administrator.
Claim Processing Turnaround Time is measured from the time the claims are received in a
BCBSTX office or Host Blue office to the time they pass all claims edits and a benefit
determination is made. Claims delayed for any reason beyond the control of Claim Administrator
(for example, when Claim Administrator is waiting on the Employer to provide membership,
eligibility, or other information) and claims that involve any investigation are excluded from
measurement
Inquiry Resolution is measured by dividing the total number of Covered Person inquiries
resolved in the number of calendar days specified in the guarantee by the total inquiries
received.
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SECTION III
TIMING
A. The period for which Claim Administrator's performance of administrative duties will be
measured and for which the Employer may receive a refund is indicated on the most
current Exhibit -PG.
B. The initial measurement of Performance Guarantees will begin on the date indicated on
the most current Exhibit -PG provided all of the requirements listed below are completed.
The requirements are as follows:
Benefit information and claims administrative procedures have been provided by
the Employer to the Claim Administrator,
2. All accumulation totals, if applicable, have been received from the prior carrier
and have been loaded onto the Claim Administrator claims processing system,
3. Accurate and complete membership information has been received and loaded
onto the Claim Administrator claims processing system, and
4. Transfer Payment procedures have been established in accordance with the
Administrative Services Agreement.
For measurement of the Performance Guarantees to continue, Transfer Payments and
all Administrative Charges must have been received by Claim Administrator in
accordance with the terms detailed in the Agreement.
C. If for any reason the Administrative Services Agreement is terminated prior to the end of
any Settlement Period or enrollment in the Plan's medical benefit coverage administered
by Claim Administrator falls below the minimum number of enrolled Subscribers
indicated in the most current Exhibit PG attached to and made a part of this Addendum,
Claim Administrator's performance of administrative duties will not be measured and the
Employer will not receive any refund, based on that part of the Settlement Period in
which the Administrative Services Agreement was in effect.
SECTION IV
DETERMINATION
A. The Claim Administrator agrees to guarantee a level of performance satisfactory
to the Employer. In the event that the Claim Administrator's level of performance
is determined to be less than any of the standards described in the most current
Exhibit -PG during any Settlement Period for any reason, except any disaster or
epidemic which substantially disrupts the Claim Administrator's normal business
operation, the Claim Administrator will be responsible for reimbursing the
Employer a portion of the Base Administrative Charge.
B. Claim Administrator will measure its performance of administrative duties and
report the measurements to the Employer, any amounts due in accordance with
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this Addendum within 120 days following the end of the Settlement Period
indicated in the most current Exhibit -PG.
C. Claim Administrator will not be obligated to measure its performance of administrative
duties and will not be obligated to refund the Employer based thereon until the
Administrative Services Agreement (including the most current Exhibit -PG) has been
executed and is on file with Claim Administrator by the close of the applicable Settlement
Period.
D. Claim Administrator will not be obligated to measure its performance of
administrative duties and will not be obligated to refund the Employer based
thereon for any portion of the Settlement Period in which the Employer:
1. Fails to provide Claim Administrator with Timely changes in enrollment or
membership information or any other reports or information as may be
necessary to Claim Administrator to perform its administrative duties,
including but not limited to identification or certification of claimants eligible for
benefits, dates of eligibility, number of employees and dependents covered
under the Plan, or
2. Fails to pay Administrative Charges in accordance with the terms of the
Agreement or comply with all established Transfer Payment procedures.
E. If for any reason there is a significant change in the benefit structure or the
administrative procedures of the medical benefit coverage administered by Claim
Administrator during any Settlement Period, Claim Administrator reserves the right to
renegotiate the level of performance and/or the Base Administrative Charges at risk in
this Addendum and the attached Exhibit -PG.
Claim Administrator will not be obligated to measure any Performance Guarantee
impacted by changes requested in writing by the Employer during the time period
required to modify the Claim Administrator system and to complete all other tasks
necessary to achieve the same qualitative standard of execution that existed before the
change was requested. All changes or amendments to the Plan must be submitted to
Claim Administrator in accordance with the Administrative Services Agreement.
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