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<br />GROUP BENEFITS SER.VICES AGREEMENT <br />NON-PARTICIPATING <br /> <br />This Agreement is between the Employer named in the Schedule and the TML Intergovernmental Employee <br />Benefits Pool, 1821 Rutherford Lane, Suite JOO, Austin, Texas 78754' .. <br /> <br />SCHEDULE <br /> <br />1. Employer: City of Paris <br />2. Effective Date: 5/1/03 <br />3. Monthly Service Charge per employee per month: <br /> <br />4. <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Q <br />0 <br />Q <br />0 <br />Q <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Q <br />Q <br />0 <br />Q <br />0 <br /> <br />. <br /> <br />Claims Administration <br />Medical <br />Medical Management <br /> <br />5/1/03 <br />$12.75 <br />$2.55 <br /> <br />Optional Services (PEPM = per employee per month; PPPP = per participant per month) <br />PPN Access Fee using direct contracts $3.75 <br />Self Funded Vision $ .50 <br />Self.funded Dental $2.15 <br />HIPAA Compliance Adm.PEPM $0.50 <br />Continuation of Coverage/Set Up $50.00 PEPM$0.50 <br />Medical Conversion PEPM $0.40 <br />Disease Management $1.50 <br />Flex Plan PPPP/Set up $50.00 enrollee $5.00 <br />Retiree Direct Billing (PRPR) $1.00 <br />Alternate Plan $1.25 <br />HealthChex - Auto Audit No Charge per Addendum A attached <br />Custom Claims Reports $150.00/programming hour <br />Rx Card Claims $ 0.32/claim PA $30.00 initial and every 6 or 12 <br />months after initial pre-authorization -pre-authorization is an optional service <br />HIP AA Certificates Included in Medical Admin Fee <br />Benefit Booklets (every 2 years) Included for Number ofEE Plus 10% <br />PPN Directories Included For Number of EE Plus 10% <br />Run-in! 90 day Run-out $12.75 per claim <br />Outpatient Audits 15% of savings - External Vendor <br />Hospital Audit 20% of savings - External Vendor <br />Subrogation 20% of savings - In.House CounsellExternal <br />Vendor <br />Out of State Network <br />Out of Network Claims (Concentra) <br />Usual and Customary (Concentra) <br />Dental Consultant <br /> <br />18% of savings - External Vendor <br />25% of savings - External Vendor <br />25% of savings- External Vendor <br />$23.00 dental, $50.00 medical, $75.00 TMJ referral <br /> <br />EXHIBIT .A. <br /> <br />Page 1 of 5 <br />