2001-043-RES AUTHORIZING EXECUTION OF GROUP BENEFITS SERVICES AGREEMENT
RESOLUTION NO. 200Hl43
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF PARIS,
PARIS, TEXAS, AUTHORIZING THE EXECUTION OF A GROUP
BENEFITS SERVICES AGREEMENT WITH TEXAS MUNICIPAL LEAGUE
INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL (TML-IEBP)
FOR TERM LIFE INSURANCE, STOP-LOSS INSURANCE FOR
MEDICAL/DENTAL/VISION PROGRAM, THIRD-PARTY
ADMINISTRATION SERVICES FOR THE ABOVE COVERAGE,
MAINTENANCE DRUG PROGRAM, AND LONG TERM DISABILITY;
MAKING OTHER FINDINGS AND PROVISIONS RELATED TO THE
SUBJECT; AND PROVIDING AN EFFECTIVE DATE.
WHEREAS, the City Council of the City of Paris did heretofore, on April 10, 2000, in
Resolution No. 2000-041, authorize the execution of a Group Benefits Services Agreement with
Texas Municipal League Intergovernmental Employee Benefits Pool (TML-IEBP) for the furnishing
and delivery of (I) Term Life Insurance, (2) Stop-loss Insurance for its otherwise self-funded
Medical!DentallVision Program, (3) Third-Party Administration Services for the above coverage, (4)
Maintenance Drug Program, and (5) Long Term Disability; and,
WHEREAS, said agreement expires on April 30, 2001, and it is deemed appropriate that a
new contract be executed; and,
WHEREAS, the form of the agreement with the Texas Municipal League Intergovernmental
Employee Benefits Pool, attached hereto as Exhibit A, should, in all things, be approved, and the
Mayor should be authorized to execute the same; NOW, THEREFORE,
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF PARIS, PARIS,
TEXAS:
Section 1. That the findings set out in the preamble to this resolution are hereby in all things
approved.
Section 2. That the form of the Group Benefits Services Agreement with the Texas
Municipal League Intergovernmental Employee Benefits Pool (TML-IEBP) for (1) Term Life
Insurance, (2) Stop-loss Insurance for its otherwise self-funded MedicallDentaVVision Program, (3)
Third-Party Administrative Services for the above coverage, (4) Maintenance Drug Program, and (5)
Long Term Disability, attached hereto as Exhibit A, be, and the same is hereby, approved.
Section 3. That the Mayor be, and he is hereby, authorized and directed to execute, on behalf
of the City of Paris, the Group Benefits Services Agreement with the Texas Municipal League, under
the terms and conditions and in the form shown in Exhibit A, attached hereto.
Section 4. That this resolution shall be effective from and after its date of passage.
PASSED AND APPROVED this 9th day of April, 200 I.
ATTEST:
~~'~~~l"k
APPROVED AS TO FORM:
~~
Mlchael 1. Pfiester, ay
GROUP BENEFITS SERVICES AGREEMENT
NON-PARTICIPATING
This Agreement is between the Employer named in the Schedule and the TML Intergovernmental
Employee Benefits Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754
SCHEDULE
1. Employer: City of Paris
2. Place of Delivery: Paris, Texas
3. Effective Date: May I, 2001
4. Monthly Service Charge per employee per month:
.
Claims Administration
Medical
Dental
Vision
Medical Management
5. Optional Services (per employee per month)
iii" PPN Access Fee using direct contracts
u(' COC Administration PEPM
D Section 125 PPPM
D HIP AA Compliance Adm.PEPM
D Medical Conversion PEPM
D Retiree/COC Direct Billing PRPM
HealthChex - Auto Audit
Custom Claims Reports
Rx Card Claims
HIP AA Certificates
Benefit Booklets (every 2 years)
PPO Directories
Run-Out
Outpatient Audits
Hospital Audit
Subrogation
Out of State Network
Out of Network Claims (Concentra)
Concentra Professional Negotiations
Disease Management
5/1/01-4/30/02
$11.50
$1.50
$0.50
$2.25
$3.00
$0.50
$5.00
$0.50
$0.40
$1.00
No Charge
$ISO.OO/programming hour
$ 0.55/claim until 10/1/01
Included in Medical Admin Fee
Included for Number ofEE Plus 10%
Included For Number ofEE Plus 10%
$12.50 per processed claim
15% ofsaviugs - External Vendor
20% of savings - External Vendor
20% of savings - In-House CounsellExternal
Vendor
18% of savings - External Vendor
20% of savings - External Vendor
25% of savings
.30 cents PEPM
~XHIBIT A
DEFlNlTIONS: The following terms where used in this Agreement, have these meanings:
o We, us, or our - The TML Intergovernmental Employee Benefits 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 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 provided by the Plan. Therefore, in
consideration of the mutual promises contained in this Agreement, it is agreed as follows.
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. We will pay benefits per your plan document
unless authorized by you, in writing, to pay outside the plan guidelines. 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 standard forms to explain benefits to employees,
standard enrollment cards, standard ill cards and one (I) standard benefit book every two
(2) years.
d. We agree to assist with underwriting services including (i) annual cost projections, (ii) cost
projections for Plan modifications; and 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.
1. 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.
\. 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. Subrogation is handled by in house counsel and a third
party vendor who retains a percent of the recovery.
n. We agree to refund all amounts paid by the specific stop loss deductible limit within ten
(10) days of receipt of payment from stop the loss carrier.
o. We agree to refund all amounts paid by the stop loss carrier for an aggregate stop loss
violation within ten (10) days of receipt of payment from the stop loss carrier.
p. We agree to provide pre-certification, 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. (This is questionable at this time)
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 a checking account at your bank, which will be used to pay all of
your claims. You will be the custodian of this account and will be responsible for
depositing all funds necessary to pay said claims. This account must utilize the 'positive
pay' feature of the banking process. Through this process, TML IEBP will be responsible
for transmitting a daily file, which gives an electronic listing of all checks written the night
before. TML IEBP will be a signer on the account for check writing purposes only. We
will use the facsimile signature of the Chairman of our Board of Trustees to sign your
checks. You agree to have your own personnel listed as authorized signers, for the purpose
of inquiries, research or reconciliation of the account.
Any fees associated with the establishment or daily process and operation of this account
will be your responsibility.
If this account is not maintained and properly funded, we may at our option, take any of the
following actions:
(i) suspend the processing and payment of your claims;
(ii) 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 thirtieth (30th) of the month or the last day of
the month.
g. You agree to act on all benefit appeals in accordance with the provisions outlined by the Plan.
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.
1. You agree to become a member of the TML Intergovernmental Employee Benefits Pool
and to be bound by the terms of the TML Intergovernmental Employee Benefits 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 IV.
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 maintain the bank account
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. You agree to pay us for any outstanding charges by the last day of the month of your
receipt of our bill. If you do not pay such charges by the end of the month, you will also
pay us for any attorney'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 of the 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.
This Agreement is made binding by the signature of your and our representatives who are duly authorized
to enter into such agreements.
For the TML Intergovernmental Employee Benefits Pool
For the City of Paris
Susan L. Smith
Print name
Michael J. Pfiester
Print name
Executive Director
Title
Mayor"
Title
April 9. 2001
Date
Date
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
ASO BANKING ARRANGEMENT
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
MAY 1,2001
THE CHECK REIMBURSEMENT FREQUENCY WILL BE PRIOR TO ISSUANCE.
AUTHORIZED OFFICIAL
TITLE Kayor
DATE April 9, 2001
ATTACHMENT A
Attachment B
HEALTHCHEX
Entity Name:
Group #:
City of Paris
APARISOl
Effective Date:
Selections:
May 1, 2001
CODE DESCRIPTIONS AND FUNCTIONS:
YES NO
[I] D RULE #00 - CANNOT PROCESS
Whenever the claim does not have the minimum of information required by the
system to perform its auditing functions, the claim will need to be placed on hold
for review.
III
D RULE #01 - OBSOLETE CODES
Whenever a procedure code is obsolete for the date of service (DOS) being billed,
it will deny. It will be replaced with the current/suggested code if one is
available.
rn D RULE #02 - EXPERIMENTAL PROCEDURES
Whenever a procedure code exclusively representing an experimental procedure
is billed, it will pend for Utilization Review.
rn
[$]
~
D RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES
Whenever a procedure code considered to be cosmetic or discretionary is billed, it
will pend for Utilization Review unless medically qualified.
D 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 procedure will deny.
D RULE #05 - SEPARATE PROCEDURES
Whenever a separate procedure, or a procedure considered to be included in the
rnajor procedure is billed, it will deny.
YES
IT]
NO
D RULE #06 - ASSISTANT SURGERY
Whenever assistant surgery is billed for a procedure that does not warrant
assistance, it will deny.
[jJ D RULE #07 - OBSTETRICAL GLOBAL FEE
Whenever office visits are billed by physician who also bills for the delivery
procedure code, and the visits are within the global fee period for the delivery, the
visits will deny, unless the visit is for a condition unrelated to the pregnancy.
rn D 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.
rn D RULE #09 - NEW PATIENT 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.
m D RULE #10 - INPATIENT IHM/DlSCHARGE CODE
Whenever a physician bills more than one initial IHM code for the same patient
for the same hospitalization, it will deny.
rn . D RULE #11 - ICU VISIT FREOUENCY
Whenever 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.
m
~
D RULE #12 -IHM VISIT FREOUENCY
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.
D RULE #13 - PHYSICIAN VISIT FREOUENCY
Whenever a physician bills for visits for the same patient for the same date of
service (DOS) (except ICU), 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.
YES NO
rn D RULE #14 - REPEAT PROCEDURES .
Whenever a physician bills for repeating a procedure within a specified period of
time after the original procedure, it will deny.
m D 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 for that procedure.
rn D RULE #16 - RADIOLOGY UNBUNDLED
Whenever rnore than one physician is billing for the same radiology episode, the
physicians are paid according to the correct component of the radiology service.
UJ D RULE #17 - MUTUALLY EXCLUSIVE PROCEDURES
Whenever a physician bills for "rnutually exclusive" procedures (can not be
performed during the same operative episode). The procedure ofthe highest value
is paid, the remaining procedure( s) are denied.
[3] D 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.
[I] D RULE #20 - MEDICAL PROTOCOL
Whenever a physician bills for a procedure more frequently than is justified by the
condition of the patient, it will pend for Utilization Review.
m D RULE #21 - FRAGMENTED PROCEDURES
Whenever a physician bills for multiple procedures on the same date of service
(DOS) that are components of a major procedure for which there is a unique
procedure code, the procedures are rebundled into the appropriate major
procedure code.
m D RULE #22 - SECONDARY PROCEDURE MANAGEMENT
Whenever a physician bills for multiple procedures, all of which qualify for
payment, the procedure of highest value is paid in full. The remaining second
procedures are reduced to the specified amount allowed for that procedure, all
other procedures are denied.
rn D 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.
YES NO
rn D RULE #24 - UTILIZATION REVIEW
Whenever a physician bills for certain procedures that usually signify upcoding,
are of questionable appropriateness, or are inherently vague, and the patient's
condition does not warrant it, it will pend for Utilization Review.
rn
[iJ
[p
D RULE #25 - CASE MANAGEMENT
Whenever a targeted procedure or diagnosis is identified, the patient's records are
flagged for a special report which is available for review to determine the need for
case management.
D RULE #26 - ASSISTANT SURGERY UCR
Whenever assistant surgery is qualified for payment, payment is reduced to not
exceed a specified amount allowed for that procedure.
D RULE #27 - CHEMISTRY LAB UNBUNDLED
Whenever a physician bills for rnore than one chemistry procedure code, they are
rebundled into the appropriate chemistry panel.
[j:] D RULE #28 - UCR/FEE SCHEDULE
Whenever a physician bills for a procedure, payment is reduced to the maximum
allowed for that procedure.
rn D RULE #29 - 31 - NO RULES CURRENTLY EXIST
rn D RULE #32 - NON-COVERED BENEFITS OR INVALID CODES
Whenever a procedure code that represents a non-covered benefit is billed it will
deny.
I];] D RULE #33 - MULTIPLE DISALLOWED PROCEDURES
Whenever a physician bills for procedures beyond the frequency for which the
procedure could possibly be performed, it will deny, (i.e. more than I
hysterectomy).
II] D 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.
rn D RULE #35 - MANDATORY OUTPATIENT PROCEDURES
Whenever a physician bills for a procedure that is generally accepted as being
done only in an ambulatory setting, however is done on an inpatient basis, it is
flagged for investigation.
YES
[3J
[Z]
rn
NO
D 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 for review.
D RULE #37 - OFFICE VISIT UPCODING
Whenever a physician bills for an extensive or comprehensive office visit that is
in excess of the appropriate frequency for that diagnosis of the patient, it is
flagged for review.
D RULE #38 - INAPPROPRIATE CODES
Whenever a procedure code that is not appropriate for the gender or age of the
patient is billed, it will deny.
[]J D RULE #39 - SENTINEL EVENTS
Whenever a physician bills for a procedure or diagnosis that is representative of a
possible quality of care issue, it is flagged for review.
rn D RULE #40 - PROVIDER CUSTOMIZATION
Whenever a physician or specialty has been customized to identify certain
procedures and/or diagnoses, they will be flagged for review.
rn
rn
rn
Signature:
D 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.
D RULE #42 - PRE-EXISTING CONDITIONS
Whenever a physician bills for services which are related to a pre-existing
condition for a new enrollee who is still in the grace period for coverage, it will be
flagged for review.
D RULE #43 - SECOND SURGICAL OPINION
Whenever a physician bills for a surgical procedure which requires a second
surgical opinion, and one has not been performed, it will be flagged for review.
Date: Aoril 9. 2001
INTERNAL USE ONLY:
Auto Audit Plant:
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
STOP LOSS/LIFE AND AD&D COVERAGE
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
MAY 1,2001
PURSUANT TO SECTION 252.021 OF THE LOCAL GOVERNMENT CODE. THE TML EMPLOYEE
BENEFITS POOL WILL PROCURE THE COVERAGE INDICATED BELOW ON BEHALF OF SAID EMPLOYER.
YES No
I x D STOP Loss COVERAGE
I X D liFE & ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
I X D LONG TERM DISABILITY
I c:!J SHORT TERM DISABILITY
NEWSPAPER OF REcORD:
The Paris News
AUTHORIZED OFFICIAL:
TITLE:
Mavor
DATE:
April 9. 2001
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
REASONABLE AND CUSTOMARY
EMPLOYER:
EFFECTIVE DATE:
CITY OF PARIS
MAY 1, 2001
THE UNDERSIGNED EMPLOYER HAS CHOSEN THE FOLLOWING PERCENTILE TO BE USED FOR
DETERMINING REASONABLE AND CUSTOMARY CHARGES. THIS SAME PERCENTILE WILL BE USED FOR
BOTH MDR AND HCPCS.
X 190TH
I 85TH
I 80TH
AUTHORIZED OFFICIAL:
TITLE:
Mavor'
DATE:
Andl 9. 2001