Laserfiche WebLink
<br />j. We agree to process any written requests, issues or comments received from Eligible <br />Persons on appeals of denied benefits and forward the information to the Employer for <br />review and decision. <br />k. We agree upon receipt of the Employer's written decision of benefit appeals, to calculate <br />any amount due and payable and make payment, or issue a denial notice, all in accordance <br />with written instructions of the Employer. <br />1. We agree to notify stop loss carriers of potential claims and provide all reporting required <br />by stop loss carriers. <br />m. We agree to provide coordination of benefit services and pursue subrogation on behalf of <br />the employer, when applicable. Subrogation is handled by a third party vendor who retains <br />a percent of the recovery. <br />n. We agree to refund all amounts paid over the specific stop loss limit within ten (10) days <br />of approval by the stop loss carrier. <br />o. We agree to refund all amounts paid over the aggregate stop loss attachment point within <br />ten (10) days of approval by the stop loss carrier. <br />p. We agree to provide precertification, continued stay review, discharge planning and large <br />case management as needed. <br />q. We agree to use the HealthChex auto-audit to review your claims at no additional cost, as <br />directed by you on Attachment B to this Agreement. <br />r. We agree to receive claims electronically for your eligible persons to the extent providers <br />are capable of electronic submission. <br />s. We agree to maintain claims processing data on microfilm or optical disk for three (3) <br />years and provide you with copies of this data for individual requests within two (2) <br />business days following receipt. <br /> <br />II. YOUR DUTIES <br /> <br />a. Yon agree to establish an arrangement with your bank whereby Federal Funds will be <br />transferred from your bank account to our bank account in accordance with Attachment A, <br />which is incorporated and made a part of this Agreement. The amount of funds requested <br />will represent the amount of funds advanced in payment of Plan benefits. If transfer of <br />funds is not accomplished we may, at our option, take any or all ofthe following actions: <br />(i) suspend benefit payment without notice; <br />(ii) assess interest on the unpaid amount at a rate not to exceed the maximum allowed <br />by law. <br />(Hi) terminate this Agreement immediately by written notice to you. <br />b. You agree to provide us in a timely fashion all information and assistance we may need to <br />properly administer the Plan. <br />c. Yon agree to verify according to your plan document, the eligibility of any persons who <br />request coverage under your plan. Your verification of eligibility will be indicated on the <br />enrollment record in the space provided for "Employer Acceptance". Once accepted by <br />you and the enrollment record received by us, those persons will be considered eligible <br />persons. <br />d. You agree to remit any premium for stop loss, life or other insured contracts by the <br />twentieth (20th) of each month and understand we do not advance premiums in your <br />behalf. I <br />e. You agree that if we or any of our agents or employees are subject to any fine, penalty, <br />loss, damage, cost, expense or legal fee because of our administration of the Plan in good <br />faith according to the terms of the Plan document, you will payor reimburse us for any <br />such fine, penalty, loss, damage, cost, expense or legal fee. In the event current revenues <br /> <br />P',,,,, 1 ()r~ <br />