1997-082-RES WHEREAS, CITY COUNCIL DID HERETOFORE ON THE 8TH DAY OF APRIL 1996
. .
RESOLUTION NO. 97 -082
WHEREAS, the City Council of the City of Paris did heretofore, on the 8th day of April,
1996, in Resolution No. 96-034, authorize the execution of a contract with Texas Municipal
League Group Benefits Risk Pool for the furnishing and delivery of (1) Term Life Insurance, (2)
Stop Loss Insurance fOT its otherwise self-funded MedicalIDentalIVision Program, (3) Third-Party
Administrative Services for the above coverage, and (4) Maintenance Drug Program; and,
WHEREAS, said contract expired on April 30, 1997, and it is deemed appropriate that
a new contract be executed; and,
WHEREAS, the form of the contTact with the Texas Municipal League Group Benefits
Risk Pool, attached hereto as Exhibit A, should, in all things, be approved, and the Mayor of the
City of Paris, Eric S. CliffoTd, should be authoTized to execute the same; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, that the
form of the contract with the Texas Municipal League Group Benefits Risk Pool, attached hereto
as Exhibit A, be, and the same is hereby, approved; and,
BE IT FURTHER RESOLVED, that Eric S. Clifford, Mayor of the City of Paris, be,
and he is hereby, authorized and directed to execute, on behalf of the City of Paris, the contract
with the Texas Municipal League Group Benefits Risk Pool for (1) Term Life Insurance, (2) Stop
Loss Insurance for its otherwise self-funded MedicalIDentalIVision Program, (3) Third-Party
Administrative Services fOT the above coverage, and (4) Maintenance Drug Program, for a term
of one (1) year, effective May 1, 1997, upon the terms and conditions and in the form shown in
Exhibit A, attached hereto.
PASSED AND ADOPTED this 14th day of July, 1997.
Ed'~~
~
ATTEST:
~~~~~~~~:J
Mattie Cunningham, City Clerk
GROUP BENEFITS SERVICES AGREEMENT
NON-PARTICIPATING
This Agreement is between the Employer named in the Schedule and the Texas Municipal League Group
Benefits Risk Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754
SCHEDULE
1. Employer: City of Paris
2. Place of Delivery: Austin, Texas
3. Effective Date: May 1, 1997
4. Monthly Service Charge:
A. Claims Administration
\ Medical $ 6.75
Dental $ 0.80
Vision $ 0.00
B. U.R. $ 1.60
C. PPO Access Fee $ 1.25
D. Centers of Excellence s.J!J..S
E. Total $10.55
F. Health Check - AutoAudit No Charge
G. Large Case Management $65.00/hr as required
H. Custom Claims Reports $60.00/programming hour
DEFINITIONS: The following terms where used in this Agreement, have these meanings:
o We, us, or our - The Texas Municipal League Group Benefits Risk Pool, known as the Group
Benefits Administrator herein, or any subcontractor which it designates to perform the functions
and meet the obligations to which it agrees in this Agreement.
o You or your - The Employer named in the Schedule.
o The Plan - The employee benefit plan which the Employer named in the Schedule has adopted to
provide medical expense benefits to eligible persons, as defined, and which is attached to and forms
a part of this Agreement.
o Eligible Persons - Employees and dependents who are eligible for benefits under the Plan.
You have adopted the Plan and asked us to administer the benefits it provides. Therefore, in consideration
of the mutual promises contained in this Agreement, it is agreed as follows.
EXHIBIT A
I. OUR DUTIES
a. We agree to process all claims presented on behalf of eligible persons for the payment of
benefits according to the terms of the Plan. Payment of claims shall be advanced by our
check subject to immediate reimbursement by you in accordance with paragraph ILa. of this
Agreement. We advance funds only for pur:poses of administrative and accounting
convenience. We do not insure the Plan. We will not pay any benefits which are not
payable under the Plan. We will not process any claim which was incurred prior to the
Effective Date shown in the Schedule, unless authorized by you in writing prior to
payment.
b. We agree to provide, at monthly intervals, a listing of all Plan benefits paid. One custom
report is provided, at your request, at no cost per plan year. Subsequent custom reports will
be billed as shown in the schedule.
c. We agree to design, review and print (i) standard forms to explain benefits to employees,
(ii) claim forms, and (iii) standard administrative forms such as enrollment cards, evidence
of good health forms and other necessary reporting forms.
d. We agree to provide actuarial services including (i) annual cost projections, (ii) cost
projections for Plan modifications; and (iii) estimates of reserve amounts required to fund
the Plan on a current basis.
e. We agree to provide assistance to you in designing your Plan benefits based on coverage
adequacy, cost control effectiveness, and medical or economic developments.
f. We agree to provide an annual report of tax reportable claim payments to medical care
providers.
g. We agree to allow you to obtain a third party to conduct an on site claims audit at our
offices. Such claims audit will be limited to once per agreement year and the date(s) will
be mutually agreed upon. We agree to not unnecessarily delay the claims audit by not
mutually agreeing to a date.
h. We agree to administer all provisions contained in the Plan booklet/document adopted by
the Employer.
i. We agree to use care and diligence in the exercise of our powers and the performance of
our duties as Group Benefits Administrator hereunder but shall not be liable for any
mistake or judgment or other action taken in good faith or for any loss unless resulting from
our gross negligence.
J. We agree to process any written requests, issues or comments received from Eligible
Persons on appeals of denied benefits and forward the information to the Employer for
review and decision.
k. We agree upon receipt of the Employer's written decision of benefit appeals, to calculate
any amount due and payable and make payment, or issue a denial notice, all in accordance
with written instructions of the Employer.
I. We agree to notify stop loss carriers of potential claims and provide all reporting required
by stop loss carriers.
m. We agree to provide coordination of benefit services and pursue subrogation on behalf of
the employer, when applicable.
n. We agree to refund all amounts paid over the specific stop loss limit within ten (10) days
of approval by the stop loss carrier.
2
o. We agree to refund all amounts paid over the aggregate ,top loss attachment point within
ten (10) days of approval by the stop loss carrier.
p. We agree to provide precertification, continued stay review, discharge planning and large
case management as needed.
q. We agree to use the HealthChex auto-audit to review your claims at no additional cost, as
directed by you on Attachment B to this Agreement.
r. We agree to receive claims electronically for your eligible persons to the extent providers
are capable of electronic submission.
s. We agree to maintain claims processing data on microfilm or optical disk for three (3)
years and provide you with copies of this data for individual requests within two (2)
business days following receipt.
II. YOUR DUTIES
a. You agree to establish an arrangement with your bank whereby Federal Funds will be
transferred from your bank account to our bank account in accordance with Attachment A,
which is incorporated and made a part of this Agreement. The amount of funds requested
will represent the amount of funds advanced in payment of Plan benefits. If transfer of
funds is not accomplished we may, at our option, take any or all ofthe following actions:
(i) suspend benefit payment without notice;
(ii) assess interest on the unpaid amount at a rate not to exceed the maximum allowed
bylaw.
(iii) terminate this Agreement immediately by written notice to you.
b. You agree to provide us in a timely fashion all information and assistance we may need to
properly administer the Plan.
c. You agree to verify according to your plan document, the eligibility of any persons who
request coverage under your plan. Your verification of eligibility will be indicated on the
enrollment record in the space provided for "Employer Acceptance". Once accepted by
you and the enrollment record received by us, those persons will be considered eligible
persons.
d. You agree to remit any premium for stop loss, life or other insured contracts by the
twentieth (20th) of each month and understand we do not advance premiums in your behalf.
e. You agree that if we or any of our agents or employees are subject to any fine, penalty,
loss, damage, cost, expense or legal fee because of our administration of the Plan in good
faith according to the terms of the Plan document, you will payor reimburse us for any
such fine, penalty, loss, damage, cost, expense or legal fee. In the event current revenues
are inadequate to fund the obligation at the time it is determined, you agree to take the
appropriate budgetary action sufficient to pay the obligation.
f. You agree to pay us a monthly service charge determined by multiplying the Monthly
Service Charge shown in the Schedule of this Agreement by the number of employees
covered under the Plan as of the first day of each calendar month commencing on the
Effective Date of this Agreement. Payment shall be due as of the first day of each calendar
month and shall be payable no later than the twentieth (20th) ofthe month.
g. You agree to act on all benefit appeals in accordance with the provisions outlined by the Plan.
3
h. You agree that if a payment is made to' or on behalf of an ineligible person or if an
overpayment is made to a covered person, the Group Benefits Administrator shall attempt, with
full cooperation and assistance of the Employer, to recover such payment through
reimbursement or from future benefits that become due to such person or entity. The Group
Benefits Administrator shall not be responsible for any such payment or overpayment unless it
was due to gross negligence of the Group Benefits Administrator.
i. You agree to become a member of the TML Group Benefits Risk Pool and to be bound by the
terms of the TML Group Benefits Risk Pool Interlocal Agreement. Where there are conflicts
between this agreement and the Interlocal Agreement, the terms of this Agreement control.
III. DURATION OF AGREEMENT
This agreement shall take effect on the effective date and shall automatically be renewed for a
successive twelve (12) month period unless terminated by either party as set forth in Section N.
Modification of the agreement is acceptable as outlined in Section V.
IV. TERMINATION OF AGREEMENT
a. You can terminate this Agreement by giving us written notice of your intent to do so, at least
31 days prior to the termination date.
b. We can terminate this Agreement:
(i) immediately, by written notice to you, if you fail to provide funds required by the Plan,
fail to pay our charges when due, or in any other way fail to perform your duties under
the Agreement;
(ii) 31 days after giving you written notice of our intent to do so.
c. Yon agree to pay us for any outstanding charges within 31 days of your receipt of our bill. If
you do not pay such charges within the 31 day period, in addition to that payment, you will also
pay us for any attorneys's fees or other collection fees we incur, plus the maximum interest
allowed by law.
d. We will have no further obligation to process claims after this Agreement terminates.
V. MODIFICATION OF AGREEMENT
a. If you and we agree on the terms of the modifications, this Agreement can be modified at any
time.
b. We can change any of the charges shown in the Schedule 31 days after giving you written
notice of our intent to do so. Such written notice shall supersede the applicable items(s) in the
schedule and any prior such notice(s). However, no such change shall take effect sooner than
the first anniversary ofthe Effective Date shown in the schedule.
VI. DISCLAIMER
We act only as a provider of services to your Plan. We do not insure your Plan in any way. We are not
a fiduciary.
4
This Agreement is made binding by the signature of your and our representatives who are duly authorized to
enter into such agreements.
For you: I
Eric S. Clifford
, the
Mavor
Title
of the
Citv of Paris~ Paris. Texas
Employer
agree on its behalf to the terms of this Agreement.
I am authorized to enter into such agreements.
Signature
ATTEST:
Witness:
.Tuly 14. 1997
Signature
Date
For us:
Terry D. Hale
Name
Executive Director
Title
for the
TML Group Benefits Risk Pool, agree on its behalf to the terms of this Agreement.
I am authorized to enter into such agreements.
Signature
Date
Witness:
Signature
Date
5
ATTACHMENT A
TEXAS MUNICIPAL LEAGUE GROUP BENEFITS RISK POOl
Aso BANKING ARRANGEMENT
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
MAY 1,1997
PLEASE CHECK THE FEQUENCY DESIRED AND EITHER ISSUED OR CLEARED.
I ISSUED I CLEARED
REIMBURSEMENT PREFUNDING PREFUNDING
FREQUENCY REQUIREMENT AMOUNT REQUIREMENT AMOUNT
5 DAYS
XI WEEKLY NONE $0.00 AVG. CLAIMS $21,813
5 DAYS 10 DAYS
I BI-WEEKL Y AVG. CLAIMS $21,813 AVG. CLAIMS $43,627
10 DAYS
I MONTHLY AVG. CLAIMS $43,627
AUTHORIZED OFFICIAL
Eric S. Clifford
TITLE
Mayor
DATE
July 14, 1997
Attachment B
HEALTHCHEX
Entity Name:
Group #:
City of Paris
AP ARISOO
Effective Date:
MIIY 1. 1997
Selections:
YES
[1]
rn
rn
rn
m
rn
[II
CODE DESCRIPTIONS AND FUNCTIONS:
NO
1>1 RULE #00 - CANNOT PROCESS
Whenever the claim does not have the minimum of information requiTed by the
system to perform its auditing functions, the claim will need to be placed on hold
fOT review.
1.1 RULE #01 - OBSOLETE CODES
Whenever a proceduTe code is obsolete fOT the date of service (DOS) being billed,
it will deny. It will be replaced with the current/suggested code if one is
available.
1...1 RULE #02 - EXPERIMENTAL PROCEDURES
Whenever a procedure code exclusively representing an experimental procedure
is billed, it will pend for Utilization Review.
1>1 RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES
Whenever a procedure code considered to be cosmetic OT discretionary is billed, it
will pend for Utilization Review unless medically qualified.
Iii RULE #04 - APPROPRIATE USE OF MODIFIERS
Whenever a modifier is used with a procedure code which should not be used with
that particular modifier, the pTocedure will deny.
II RULE #05 - SEPARATE PROCEDURES
WheneveT a separate procedure, OT a procedure considered to be included in the
major procedure is billed, it will deny.
liil RULE #06 - ASSISTANT SURGERY
WheneveT assistant surgery is billed for a procedure that does not warrant
assistance, it will deny.
YES
[]J
IE
I];]
(]J
[lJ
rn
[J;]
NO
I' I RULE #07 - OBSTETRICAL GLOBAL FEE
Whenever office visits are billed by physician who also bills fOT the delivery
procedure code, and the visits are within the global fee period for the delivery, the
visits will deny, unless the visit is fOT a condition unrelated to the pregnancy.
liil RULE #08 - SURGICAL GLOBAL FEE
Whenever a physician bills office visits, consults or hospital visits within the
global fee period for the surgical procedure, the visits will deny. There are
exceptions to this rule, for instance, a diagnostic procedure, as well as any visit
which is for a condition unrelated to the surgery.
Ii .>1 RULE #09 - NEW P A TrENT CODE
Whenever a physician bills more than one new patient procedure code for the
same patient, it will deny, and insert a more appropriate visit code associated with
an established patient and allow payment accordingly.
1....1 RULE #10 - INP A TrENT IHMIDISCHARGE CODE
Whenever a physician bills more than one initial IHM code fOT the same patient
for the same hospitalization, it will deny.
II RULE #11 - ICU VISIT FREOUENCY
WheneveT a physician bills more than a specified number of visits for the same
patient for the same date of service (DOS), the subsequent visit will pend for
Utilization Review.
Ii I RULE #12 - IHM VISIT FREQUENCY
Whenever more than one physician bills for the same date of service (DOS) for
the same patient, and each is billing for a condition within the same "body
system", the later claims will be denied.
1.1 RULE #13 - PHYSICIAN VISIT FREOUENCY
Whenever a physician bills for visits fOT the Same patient for the same date of
service (DOS) (except I CU), the visit of highest value is paid and the other visits
will deny. If the other visits are for different diagnoses, however, they will be
allowed.
I~l II RULE #14 - REPEAT PROCEDURES
WheneveT a physician bills for repeating a procedure within a specified peTiod of
time after the original procedure, it will deny.
[U
Ii> I RULE #15 - PROFESSIONAL COMPONENT
When the physician is billing for the professional component of a procedure only,
the corresponding technical component is reduced, so that the total does not
exceed the maximum allowed fOT that procedure.
YES
IYl
~
[J]
NO
II RULE #16 - RADIOLOGY UNBUNDLED
Whenever more than one physician is billing for the same radiology episode, the
physicians are paid according to the correct component ofthe radiology service.
I> I RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES
Whenever a physician bills for "mutually exclusive" pTocedures (can not be
performed during the same operative episode). The pTocedure of the highest value
is paid, the remaining procedure(s) are denied.
1".1 RULE #18 - POST-OP CARE. RULE #19 - PRE-OP CARE
Whenever a physician is billing for care before or after a procedure that another
physician has performed, and if the care is within the global fee period of the
procedure and for a related condition, it will be denied.
II]] I., I RULE #20 - MEDICAL PROTOCOL
WheneveT a physician bills for a procedure more frequently than is justified by the
condition of the patient, it will pend for Utilization Review.
l1i.f 1..1 RULE #21 - FRAGMENTED PROCEDURES
Whenever a physician bills for multiple proceduTes on the same date of service
(DOS) that are components of a major procedure for which there is a unique
proceduTe code, the procedures are rebundled into the appropriate majoT
procedure code.
1rf.1 II RULE #22 - SECONDARY PROCEDURE MANAGEMENT
Whenever a physician bills fOT multiple procedures, all of which qualify for
payment, the procedure of highest value is paid in full. The Temaining second
procedures are reduced to the specified amount allowed fOT that procedllTe, all
other procedures are denied.
1.'1-1 1.1 RULE #23 - BILATERAL PROCEDURE MANAGEMENT
Whenever a physician bills for a bilateral procedure, the payment is reduced to not
exceed the maximum allowed for that procedure.
rn
D
RULE #24 - UTILIZATION REVIEW
Whenever a physician bills for certain procedures that usually signify upcoding,
aTe of questionable appropriateness, or are inherently vague, and the patient's
condition does not warrant it, it will pend fOT Utilization Review.
l.C:I:..1 1..1 RULE #25 - CASE MANAGEMENT
Whenever a targeted procedure or diagnosis is identified, the patient's records are
flagged fOT a special report which is available fOT review to determine the need for
case management.
YES NO
I '/.;.1 lii,1 RULE #26 - ASSISTANT SURGERY UCR
Whenever assistant sUTgery is qualified for payment, payment is Teduced to not
exceed a specified amount allowed for that procedure.
1,,,,-1 I. ii.i I RULE #27 - CHEMISTRY LAB UNBUNDLED
Whenever a physician bills for more than one chemistry procedure code, they are
rebundled into the appropriate chemistry panel.
[II 1>1 RULE #28 - UCR/FEE SCHEDULE
WheneveT a physician bills for a procedure, payment is reduced to the maximum
allowed fOT that procedure.
liUl 1>1 RULE #29 - 31 - NO RULES CURRENTLY EXIST
I~ I EJ RULE #32 - NON-COVERED BENEFITS OR INVALID CODES
WheneveT a procedure code that represents a non-covered benefit is billed it will
deny.
I-\<l Ii il RULE #33 - MULTIPLE DISALLOWED PROCEDURES
Whenever a physician bills for proceduTeS beyond the frequency for which the
pToceduTe could possibly be performed, it will deny, (i.e. more than 1
hysteTectomy).
[ill.J 1>1 RULE #34 - DUPLICATE PROCEDURES
Whenever a physician bills the same procedure code more than once for the same
patient on the same date of service (DOS) it will deny.
1'\.0:1 Iii RULE #35 - MANDATORY OUTPATIENT PROCEDURES
Whenever a physician bills fOT a pTocedure that is generally accepted as being
done only in an ambulatory setting, however is done on an inpatient basis, it is
flagged for investigation.
I~I liU I RULE #36 - POTENTIAL COORDINATION OF BENEFITS
Whenever a physician bills for a diagnosis that is representative of possible motor
vehicle accident origin or workers' compensation, it is flagged fOT review.
EEt1] Id RULE #37 - OFFICE VISIT UPCODING
WheneveT a physician bills for an extensive OT comprehensive office visit that is
in excess of the appropriate frequency for that diagnosis of the patient, it is
flagged for review.
YES NO
IJI:E] 1"1 RULE #38 - INAPPROPRIATE CODES
Whenever a pTocedure code that is not appTopriate for the gender or age of the
patient is billed, it will deny.
I,~I I" I RULE #39 - SENTINEL EVENTS
Whenever a physician bills for a proceduTe or diagnosis that is Tepresentative of a
possible quality of care issue, it is flagged for review.
I'W:I 1,1 RULE #40 - PROVIDER CUSTOMIZATION
WheneveT a physician or specialty has been customized to identify certain
procedures and/or diagnoses, they will be flagged for review.
IAI Iii RULE #41 - PROCEDURE AND DIAGNOSIS CODE COMPATIBILITY
Whenever a physician bills for a condition unrelated to a procedure which is also
being billed for, it is flagged for review.
I:"\,il 1,1 RULE #42 - PRE-EXISTING CONDITIONS
WheneveT a physician bills for services which are related to a pre-existing
condition for a new enrollee who is still in the grace peTiod for coveTage, it will be
flagged for review.
1-\....1 1'.:1 RULE #43 - SECOND SURGICAL OPINION
Whenever a physician bills for a surgical procedure which TequiTes a second
surgical opinion, and one has not been performed, it will be flagged for review.
Signature:
Eric S. Clifford, Mayor
Date:
luly 14 lqq7
Attachment C
TEXAS MUNICIPAL LEAGUE GROUP BENEFITS RISK POOL
STOP LOSS/lifE AND AD&D COVERAGE
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
MAY 1, 1997
PURSUIT TO SECTION 252.021 OF THE LOCAL GOVERNMENT CODE. THE TEXAS MUNICIPAL
LEAGUE GROUP BENEFITS RISK POOL WILL PROCURE THE COVERAGE INDICATED BELOW ON
BEHALF OF SAID EMPLOYER.
YES No
I i-- D STOP Loss COVERAGE
I '\- D LIFE & ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
I [::::IJ LONG TERM DISABILITY
I [i] SHORT TERM DISABILITY
AUTHORIZED OFFICIAL
Er1C s. C1~fford
TITLE Mayor
DATE July 14, 1997
ASU/sg
stoploss.doc