2003-062-RES AUTHORIZATION OF GROUP BENEFITS AGREEMENT WITH TML-IEP
RESOLUTION NO.
2003-062
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/DENT AL/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 the 8th day of April,
2002, in Resolution No. 2002-065, 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(1) Term Life Insurance, (2) Stop-loss Insurance for its otherwise self-
funded MedicallDentallVision 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, 2003, and it is deemed appropriate that a
new contract be executed; 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 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
Intergovernmental Employee Benefits Pool (TML-IEBP) for (1) Term Life Insurance, (2) Stop-loss
Insurance for its otherwise self-funded MedicalIDentalNision Program, (3) Third-Party
Administrative Services for the above coverage, (4) Maintenance Drug Program, and (5) Long Term
Disability, under the terms and conditions and in the form shown in Exhibit A, attached hereto, and
any and all other documents as may be necessary.
Section 3. That this resolution shall be effective from and after its date of passage.
PASSED AND APPROVED this 14th day of April, 2003.
~~
ATTEST:
APPROVED AS TO FORM:
GROUP BENEFITS SER.VICES AGREEMENT
NON-PARTICIPATING
This Agreement is between the Employer named in the Schedule and the TML Intergovernmental Employee
Benefits Pool, 1821 Rutherford Lane, Suite JOO, Austin, Texas 78754' ..
SCHEDULE
1. Employer: City of Paris
2. Effective Date: 5/1/03
3. Monthly Service Charge per employee per month:
4.
0
0
0
0
0
0
Q
0
Q
0
Q
0
0
0
0
0
0
0
0
Q
Q
0
Q
0
.
Claims Administration
Medical
Medical Management
5/1/03
$12.75
$2.55
Optional Services (PEPM = per employee per month; PPPP = per participant per month)
PPN Access Fee using direct contracts $3.75
Self Funded Vision $ .50
Self.funded Dental $2.15
HIPAA Compliance Adm.PEPM $0.50
Continuation of Coverage/Set Up $50.00 PEPM$0.50
Medical Conversion PEPM $0.40
Disease Management $1.50
Flex Plan PPPP/Set up $50.00 enrollee $5.00
Retiree Direct Billing (PRPR) $1.00
Alternate Plan $1.25
HealthChex - Auto Audit No Charge per Addendum A attached
Custom Claims Reports $150.00/programming hour
Rx Card Claims $ 0.32/claim PA $30.00 initial and every 6 or 12
months after initial pre-authorization -pre-authorization is an optional service
HIP AA Certificates Included in Medical Admin Fee
Benefit Booklets (every 2 years) Included for Number ofEE Plus 10%
PPN Directories Included For Number of EE Plus 10%
Run-in! 90 day Run-out $12.75 per claim
Outpatient Audits 15% of savings - External Vendor
Hospital Audit 20% of savings - External Vendor
Subrogation 20% of savings - In.House CounsellExternal
Vendor
Out of State Network
Out of Network Claims (Concentra)
Usual and Customary (Concentra)
Dental Consultant
18% of savings - External Vendor
25% of savings - External Vendor
25% of savings- External Vendor
$23.00 dental, $50.00 medical, $75.00 TMJ referral
EXHIBIT .A.
Page 1 of 5
DEFINITIONS: The following terrps \vhere used in this Agreement, have these me1'loings:
~ 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.
~ You or your - The Employer named in the Schedule.
);0- 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.
)!> Eligible Personli - 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
~. 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 administer benefits per your plan
document unless authorit:ed 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 determination.
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 lD cards and one (1) standard benefit book every two
(2) years.
d. We agree to provide underwriting services including (i) annual cost projections, (ii) cost
projections tor Plan modifications; and estimates of reserve amounts required to fund the
Plan on a CUtTent 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 sit~ 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.
Page 2 of 5
k. We agree upon receipt of th~ Employer's written decision of benefit app~als, to c;llcul;lte
any amount due and payable, or issue a denial notice, all in accordance with written
iustructions of the Employer.
1. We aeree to notifY stop loss carriers of potential claims and provide all reporting required
by stop loss carriers.
m. We llgree 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 Ii percent of the recovery.
n. We agree to retund all amounts paid over the specific stop loss limit within ten (10) days
of approval by the stop loss carrier.
o. We agree to l'dund all amounts paid over the aggregate stop loss attachment point within
ten (10) days of approval by 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 Addendum 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.
t. We agree to provide your bank with a daily 'positive pay' file, which documents which
claims were paid each business day.
II. YOUR DUTIES
a. Y 011 agree to establish a checking account at your bank, which will be used to pay all of
your claims per Addendum A. 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) tem1inate 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
Page J of 5
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 contractf; 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 temlS 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 <<harge detelmined by multiplying the Monthly
Service Charge shO\v11 in the Schedule of this Agreement by the number of employees
coverl;Jd 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.
I. You agree to become a member of the TML Intergovernmental Employee Benefits Pool
and to be bound by the tenns of the TML Intergovernmental Employee Benefits Pool
Interlocal Agreement.
III. DURATION OF AGREEMENT
This agreement shall take effect on the effective datc and shall automatically be renewed for a
successivc twelve (12) month period unless ternlinated by either party as set forth in Section IV.
Modification of the agreement is acceptablc 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.
Pug.: 4 of 5
v. MODIFICATION OF AGREEMENT
a. If you and we agree on the ternlS of the modifications, this Agreement can be modified at
any time.
b. We can chan~e 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 sibrnaturc of your and our representatives who are duly authorized
to enter into such agreements.
For the TML Intergovernmental Employee Benet1ts Pool
City of Paris
Susan L. Smith
Print name
Michael J. Pfiester
Print name
Executive Director
Title
Mayor
Title
Date
April 14, 2003
Date
Page 5 of 5
ADDENDUM A
TML INTERGOVERNMI!NTAL I!MPLOYl!e BeNEFITS POOL
ASO BANKING ARRANGEMENT
EMPLOYER: CITY OF PARIS .
EFFECTIVE DATE: 5/1/03
THE CHECK REIMBURSEMENT FREQUENCY WILL BE PRIOR TO CLAIM ISSUANCE.
AUTHORIZED OFFICIAL
TITLE ~Qr
DATE ~Dril t4. 200~
CHECK TRACER STATUS PROCEDURE
$25.00 FEE FOR CHECKS OVER 90 DAYS OLD
$50.00 FEE FOR CHECKS ISSUEDPRIOR TO 10/1/99
ALL FEES PAYABLE PRIOR TO INQUIRY BEING INITIATED. FEES WILL BE CHARGED TO ANYONE
REQUESTING CHECK STATUS >90 DAYS OLD.
AUTHORIZED OFFICIAL
TITLE Mavor
DATE ADril 14. 2003
Addendum B
HEALTHCHEX
CITY OF PARIS
APAnSOl
Entity Name:
Group #:
Effective Date: 5/1/03
Selections: CODE DESCRIPTIONS AND FUNCTIONS:
YES
[iJ
[iJ
[!]
[!]
m
[!]
[!]
NO
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.
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.
D RULE #02 - EXPERIMENTAL PROCEDURES
Whenever a procedure code exclusively representing an experimental procedure is
billed, it will pend for Utilization Review.
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 procedllre code which should not be used with
that particular modifier, the procedure will deny.
D RULE#05-SEPARATEPROCEDURES
Whenever a separate procedure, or a procedure considered to be included in the
major procedure is billed, it will deny.
D RULE #06 - ASSIST ANT SURGERY
Whenever assistant surgery is billed for a procedure that does not warrant
assistance, it will deny.
YES NO
lIJ [J 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.
[iJ D RULE #08 .. ~URGIC~k GLOBAI;t 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
e.xce.ptions to this rule. for instance, a diagnostic procedure, as well as any visit
which is for a Qundition I.mr~lated to th~ sur~ery.
[jJ D R.ULE#~9..: N~:W.P~TI.~~:r 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.
[!] D RULE #10 - INPATIENT IBM/DISCHARGE CODE
Whenever a physician bIlls more than one initial IHM: code for the same patient
for the same hospitalization, it will deny.
II]
D
RULE #11 ~ ICU VISIT FREQUENCY
. . '., .' .-. - . ... -. -,"
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
Vtilization R~vi~w.
[!] D 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 lat~r claims will be denied.
[!J
D
RULE #13 - PHYSICIAN VISIT FREQUENCY
Whenever a physician bills for visits for the same patient for the same date of
service (DOS) (except leU), the visit of highest value is paid and the other visits
will deny. If the other visits are for different diagnoses, how~ver, they will be
allowed.
IT] 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.
[!J
D 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 of the radiology service.
YES NO
I:iJD
I:iJ
m
m
m
II]
[!]
RULE #17.. MUTUALLY EXCLUSIVE PROCEDURES
Whenever a physician bills for "mutually exclusive". procedures (can not be
performed during the same operative episode). The procedure of the highest value
is paid, the remaining procedure(s) are denied.
D
RULE #18 R 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.
D RULE #20 .. MEDICAL PROTOCOL
Whenever a physician bills for a procedure more frequently than is justified by the
condition o[the patient, it will pend for Utilization Review.
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.
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.
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.
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.
ED
[!J
III
m
[!]
[iJ
[!J
IT]
IT]
[!]
[iJ
o 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 detennine the need for
ca!i~ management.
D -~U~E #2'7 - ~IlliMI~TRY LAB UNBUNDLED
Whenever a physician bills for more than one chemistry procedure code. they are
rebundled into the appropriate chemistry panel.
D ~ULF.3. ~29:~ 31 :NO RVJ..t:S CU~NTLYE~~ST
D RULE #32 ... NON..COV.E~n Bf:NEfll~ ORINV ALID CODES
Whenever a procedure code that represents a non~covered benefit is billed it will
dellY.
o RULE #33 - MULTIPLE DISALLOWED PROCEDURES
Whenever a physician bills for procedures beyond the frequency for which the
procedure could possibly be perfonned, it will deny, (i.e. more than 1
hystc;rectomy).
o ~U~~ ~3.4_: D(JPLICATEPROCEDURES
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.
o 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.
o
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.
o 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.
o 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.
o RULE #40- PROVIDER CUSTOMIZATION
Whenever a physician or lipecialty has been customized to identifY certain
procedures and/or diagnoses, they will be flagged for review.
[i] 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.
m 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.
Signature:
Date: AP:r.~~ 14~. 2003
INTERNAL USE ONLY:
Auto Audit Plan #:
ADDENDUM C
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
STOP LOSS/LIFE AND AD&D COVERAGE
EMPLOYER: CITY OF PARIS
EFFECTIVE DATe: 5/1/03
PURSUANT TO SECTION 252.021 OF THE LOCAL. GoveRNMeNT COI;)~, THE TML EMPI,.0YEE
BENEFITS POOL WILL p~ocu~e THE COVERAGE INDICATED BELOW ON BEHALF OF SAID
EMPLOYER.
YES No
I x Ii STOP Loss COVERAGE
I x. D LIFE & ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE
I x I I LONG TERM DISABILITY
I [I] SHORT TERM DISABILITY
NEWSPAPER OF RECORD:
The Paris News
AUTHORIZED OFFICIAL:
TITLE:
H3:~or
~~ .' .,
DATE:
April 14, 2003
APDENDUM D
TML INTERGOVERNMENTAL EMPLOYEE BENEFITS POOL
REASONABLE AND CUSTOMARY
EMPLOYER: CITY 0F PARIS
EFFECTIVE DATE: 5/1103
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.
I-~ J 90TH
I - -I 80TH
I... I 80TH
AUTHORIZED OFFICIAL:
TITLE:
~~~r
.. .. ---- -- _.,. .
.. -~.
-."" .'.
DATE:
April 14, 2003
ADDENDUM ~
TML INTERGOV~RNME~AL EMPLOYEE BENEFIT$ POOL
USUAL ANO CUS~OMAR~ eHARGB ~ALYSIS
EMPLOYER: CITY OF PARIS
EFFECTIVE PATE: ~/~/Q3
THE UNDERSIGNED EMPLOYER HAS CHOSEN TO HAVE USUAL AND CUSTOMARY
CHARGE ANALYSIS ( COST TO CHARGE OR "C2C") PERFORMED BY AN
EXTERNAL VENDOR ON ALL HOSPITAL CHARGES THAT ARE NOT PER DIEM OR
CASE RATED IN EXCESS OF $25,000.00 . THE FEE FOR THIS SERVICE
SHALL EE 25% PERCENT OF SAVINGS. .
EMPLOYER AUTHORI4ED OFFICIAL SIGNATURE:
TITLE: MayO!
DATE:
April 14. 2003