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ES12-006 - Original - Premera Blue Cross - Contract - 01/01/2012
Records Mao - - g' e e 6 a KENT Document wh9HINGTDN CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to City Clerks Office. All portions are to be completed. If you have questions, please contact City Clerk's Office. Vendor Name: Premera Blue Cross Vendor Number: ID Edwards Number Contract Number: ©O This Is assigned by City Clerk's Office Project Name: Claims Administrator Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment M Contract ❑ Other: Contract Effective Date: 1/1/2012 Termination Date: 12/31/2012 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: B Fowler Department: Employee Services Detail: (i.e. address, location, parcel number, tax id, etc.): CM121311 S•Publlc\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08 3 i s ADMINISTRATIVE SERVICE CONTRACT BETWEEN PREMERA BLUE CROSS AND CITY OF KENT EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012 (The "Contract Period") This Contract is effective by and between the group named above(hereinafter referred to as the"Plan Sponsor'), and Premera Blue Cross (hereinafter referred to as the"Claims Administrator"or"we,""us," or"our") WHEREAS, the Plan Sponsor has established an employee benefit plan (hereinafter referred to as the"Plan") which provides for payment of certain welfare benefits to and for certain eligible individuals as defined in writing by the Plan Sponsor, such individuals being hereinafter referred to as "Members", and, WHEREAS, the Plan Sponsor has chosen to self-insure the benefit program(s) provided under the Plan, and WHEREAS, the Plan Sponsor desires to engage the services of the Claims Administrator to provide administrative services for the Plan, NOW THEREFORE, in consideration of the mutual covenants and conditions as contained herein the parties hereto agree to the provisions in this Contract, including any Attachments and endorsements thereto The parties ; below have signed as duly authorized officers and have hereby executed this Contract If this Contract is not signed and returned to the Claims Administrator within sixty(60) days of its delivery to the Plan Sponsor or its agent, the Claims Administrator will assume the Plan Sponsor's concurrence and the Plan Sponsor will be bound by its terms IN WITNESS WHEREOF the parties hereto sign their names as duly authorized officers and have executed this Contract City of Kent BY DATE a 17 Tit ADDRESS .Ke.A-i �Pft� �d�o 3 Premera Blue Cross BY DATE January 1, 2012 H.R. Brereton Barlow President and Chief Executive Officer P O Box 327 - Seattle,WA 98111-0327 ADSERV-ASC(01-2012) TABLE OF CONTENTS 1. DEFINITIONS........................................................................................................................4 2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR............................................4 21 Documentation 4 22 Plan Sponsor's Fiduciary Authority 4 23 Defense of the Plan 4 24 Administrative Duties 5 25 Taxes,Assessments,And Fees 5 26 Compliance With Law 5 27 Appeals 6 28 Funding 6 3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR............................6 31 Administrative Duties 6 32 Appeals 7 33 Claims Administrator's Fiduciary Authority 7 34 Claims Processing . .......... . .,... 8 35 Funding Support . . 8 36 Annual Accounting 8 37 Participation In Class Action Suits 8 4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY......................................9 4 1 Recoveries 9 4 2 Independent Contractor 9 4 3 Limits of Liability 9 6. FEES OF THE CLAIMS ADMINISTRATOR..........................................................................9 51 Payment Time Limits 9 5 2 Late Payments 9 5 3 Customization Fees 10 6. AUDIT..................................................................................................................................10 7. SUBROGATION..................................................................................................................10 8. TERM OF CONTRACT........................................................................................................11 8 1 Contract Period 11 8 2 Changes to Fees 11 9. TERMINATION....................................................................................................................11 9 1 Termination With Notice 11 9 2 Contract Period Expiration 11 City of Kent January 1,2012 1018212 1 93 Termination Due to Insolvency. ... ....... ..... . .. ...... ...... . . .... ...... .11 j 94 Termination Due to Inability to Perform 12 95 Termination For Nonpayment 12 96 Plan Sponsor Liability Upon Termination . 12 97 Final Accounting 12 98 Claims Runout 12 10. DISCLOSURE...................................................................................................................13 11. OTHER PROVISIONS.......................................................................................................13 11 1 Choice of Law 13 11 2 Proprietary Information 13 11 3 Parties To The Contract 13 114 Notice 13 11 5 Integration 14 116 Assignment... 14 12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT .............................14 ATTACHMENT A— OUT-OF-AREA SERVICES......................................................................15 Return of Overpayments 16 BlueCard Worldwide° 16 Fees and Compensation 16 ATTACHMENT B—CENSUS INFORMATION.........................................................................18 ATTACHMENTC— REPORTING ............................................................................................19 ATTACHMENT D— FEES OF THE CLAIMS ADMINISTRATOR.............................................20 ATTACHMENT E— BUSINESS ASSOCIATE AGREEMENT ..................................................22 ATTACHMENT F —CARE FACILITATION..............................................................................23 ATTACHMENT G — EXTENDED POST-PAYMENT RECOVERY SERVICES.........................24 ATTACHMENT H — DISEASE MANAGEMENT.......................................................................26 Appendix 1 Services 27 City of Kent January 1,2012 1018212 1. DEFINITIONS Adverse Benefit Determination Any of the following- a denial, reduction, or termination of, or a failure to provide or make payment(in whole or in part)for, a benefit, including payment that is based on a determination of the eligibility of a Member to participate in the Plan This includes any denials, reductions, or failures to provide or make payment resulting from the application of utilization review or limitations on experimental and investigational services, medical necessity, or appropriateness of care It also includes a decision to rescind a member's coverage unless the rescission is due to nonpayment of subscription charges Affordable Care Act The Patient Protection and Affordable Care Act of 2010 (Public Law 111-148)as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152) Contract Period The period shown on the Face Page of this Contract The Contract Period begins at 12 01 a m on the starting date shown on the Face Page and ends at midnight on the ending date shown on the Face Page Effective Date The date this Contract takes effect(the first day of the Contract Period) The Effective Date is shown on the Face Page of this Contract Grandfathered Health Plan A Plan benefit package that meets the requirements to be a"grandfathered health plan"set forth in the federal Affordable Care Act regulations If the Plan consists of more than one benefit package, the federal regulations on grandfathered plan status apply separately to each benefit package Member A Subscriber or dependent who is eligible for coverage as stated in the Plan and who is enrolled as required in the Plan Non-Grandfathered Health Plan A Plan benefit package that does not meet the requirements to be a grandfathered health plan set forth in the federal Affordable Care Act regulations If the Plan consists of more than one benefit package, the federal regulations on non-grandfathered plan status apply separately to each benefit package PEPM "Per employee per month" Plan The employee benefit plan established and maintained by the Plan Sponsor that is being administered under this Contract The Plan may consist of one or more benefit packages Subscriber A person who is eligible for coverage under the plan by virtue of an employee-employer relationship or other relationship between the person and the Plan Sponsor, and who is enrolled as required in the Plan 2. DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR 2.1. Documentation The Plan Sponsor shall provide the Claims Administrator with a copy of any documents describing the benefit program(s)that the Claims Administrator needs to rely upon in performing its responsibilities under this Contract 2.2. Plan Sponsor's Fiduciary Authority The Plan Sponsor shall have final discretionary authority to determine the benefit provisions and to construe and interpret the terms of the Plan The Plan Sponsor shall have final discretionary authority to determine eligibility for benefits and the amount to be paid by the Plan 2.3. Defense of the Plan The Plan Sponsor shall be responsible for defending any legal action brought against the Plan, including a claim for benefits by or on behalf of any individual or entity, including but not limited to any Member or former Member, City of Kent January 1,2012 1018212 i I any fiduciary or other party This responsibility includes the selection and payment of counsel The Plan Sponsor shall not settle any legal action or claim without the prior consent of the Claims Administrator if the action or claim could result in the Claims Administrator being liable, including for example, any liability for contribution to or indemnification of the Plan Sponsor or other third party either directly or indirectly 2.4. Administrative Duties a Unless specifically delegated to the Claims Administrator by this Contract,the Plan Sponsor shall be responsible for the proper administration of the Plan including the following a The Plan Sponsor shall provide the Claims Administrator a complete and accurate list of all individuals eligible for benefits under the benefit program(s) and to update those lists monthly The Claims Administrator shall be entitled to rely on the most recent list until it receives documentation of any change thereto Retroactive enrollments shall be effective on the most recent of two dates • The date the member's coverage would have been validly in force • The first day of the fifth full calendar month preceding the month in which the Claims Administrator receives the request for retroactive enrollment Retroactive terminations of coverage shall be effective on the most recent of two dates: • The date the member's coverage would have been terminated, had notification been timely • The first day of the fifth full calendar month preceding the month in which the Claims Administrator receives the request for retroactive termination b. The Plan Sponsor shall distribute to all eligible Members all appropriate and necessary materials and documents, including but not limited to benefit program booklets, summary plan descriptions, material modifications, enrollment applications and notices required by law or that are necessary for the operation of the Plan c The Plan Sponsor shall provide the Claims Administrator with any additional information necessary to perform its functions under this Contract as may be requested by the Claims Administrator from time to time d If the Plan Sponsor writes or revises its benefit booklet, the Claims Administrator must review and approve in advance the draft of the benefit booklet that is printed and distributed to Members The Plan Sponsor must also include BlueCard disclosure language approved by the Blue Cross Blue Shield Association in its booklet 2.5. Taxes, Assessments, And Fees The Plan Sponsor shall be responsible for all taxes, assessments and fees levied by any local, state or federal authority in connection with the Claims Administrator's duties pursuant to this Contract 2.6. Compliance With Law • The Plan Sponsor shall be responsible for the Plan's continuing compliance with all applicable federal, state and local laws and regulations, as currently amended These include but are not limited to • The Internal Revenue Code • The Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010 (the"Affordable Care Act") • The Health Insurance Portability and Accountability Act of 1996(HIPAA) • The Consolidated Omnibus Budget Reconciliation Act of 1985(COBRA) • Law and regulations governing the treatment and benefits of members covered by Medicare These include, but are not limited to, the Medicare Secondary Payer law and regulations and the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) As required by MMSEA, the Plan Sponsor agrees to provide us the following information City of Kent January 1,2012 1018212 Employer Tax Identification Number(TIN/EIN); • Social Security Numbers (SSNs) of all members(employees and dependents), and • Medicare Health Insurance Claim Numbers (HICNs)for all Medicare-entitled members To comply with the Medicare Secondary Payer law and regulations,the Plan Sponsor also agrees to notify us promptly if the Plan Sponsor experiences a change in total employee count that would change the order of liability according to federal guidelines The Plan Sponsor, and not the Claims Administrator, is the"plan administrator"and the"plan sponsor"for purposes of all federal laws that apply to the Plan Sponsor and impose duties or obligations on such entities The Plan Sponsor shall be responsible for determining whether it is subject to COBRA and, if so, for notifying Members of their COBRA rights both initially and upon the occurrence of a qualifying event, for calculating and collecting premiums for COBRA continuation of coverage and for promptly notifying the Claims Administrator when an individual is no longer eligible for COBRA continuation of coverage If the Plan Sponsor is subject to ERISA, the Plan Sponsor is responsible to prepare and maintain its ERISA plan document • If the Plan Sponsor elects to opt out of compliance with certain federal mandates as allowed by HIPAA, the Plan Sponsor is responsible to file its opt-out with federal regulators for each contract period and to notify Members of the opt-out in accordance with federal law and regulations then in effect The Plan Sponsor agrees to hold the Claims Administrator and the Network harmless for any and all consequences arising from the Plan Sponsor's failure to file an opt-out as required by law for a given contract period, errors in the opt-out filing, or failure to notify a Member as required by federal law 2.7. Appeals If an adverse decision on a Member appeal results from the Plan's internal appeal process, the Plan shall offer the Member a review by an Independent Review Organization (IRO) as described in subsection 3 2 2.8. Funding The Plan Sponsor shall be solely liable for all benefits payable to members under the Plan that are subject to this Contract The Plan Sponsor agrees to the following a Provision Of Funds The Plan Sponsor shall maintain adequate funds from which the total cost of all claims for each preceding week will be paid to the Claims Administrator by electronic funds transfer (EFT) Funds must be provided within two(2) business days of notification by the Claims Administrator to a person designated by the Plan Sponsor b Late Payments If timely payment for the claims is not received by the Claims Administrator, the Plan Sponsor shall pay the Claims Administrator a daily late charge This late charge is calculated from the first day following the period of two(2) business days stated above This late charge is based on the average monthly prime rate posted by Claims Administrator's designated bank during the Contract Period, plus two (2) percent on the amount of the late payments for the number of days late Late charges are due at the end of the Contract Period as part of the annual accounting or, if earlier, upon termination of the Contract c Notices Notices required by this subsection and subsection 3 5 shall be by secure e-mail unless another method is agreed upon in writing by the Plan Sponsor and the Claims Administrator 3. DUTIES AND RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR 3.1. Administrative Duties The Claims Administrator agrees to perform the following administrative services for the Plan Sponsor The Claims Administrator shall a assist in the preparation and printing of the benefit program booklets, identification cards, and other materials necessary for the operation of the Plan, and distribute identification cards to Members City of Kent January 1,2012 1018212 S A The Claims Administrator shall be responsible to include approved BlueCard program disclosure language in the booklets it prepares If the Plan Sponsor prepares its own booklets, the Claims Administrator shall provide approved language to the Plan Sponsor for inclusion in the booklets, b perform reasonable internal audits as stated in section 6 of this Contract, c answer inquiries from the Plan Sponsor, Members, and service providers regarding the terms of the Plan, although final authority for construing the terms of the Plan's eligibility and benefit provisions is the Plan Sponsor's, d prepare and provide the Plan Sponsor with reports of the operations of the Plan in accordance with "Attachment C—Reporting", e coordinate with any stop-loss insurance carrier, f when "preferred provider"or"network provider' benefits are provided, maintain a network of hospital and professional providers, paid claims will reflect any applicable provider discounts, g perform care facilitation services as identified in"Attachment F—Care Facilitation" h provide a Certificate of Group Health Coverage to Members when their coverage under this Plan terminates or upon their request within 24 months of termination i Brand-name prescription drug rebates are guaranteed on a per-prescription basis The Claims Administrator will pay to the Plan Sponsor the full amount of guaranteed rebates received by the Claims Administrator in connection with the Plan Sponsor's pharmacy benefit utilization Payment shall be made to the Plan Sponsor on a calendar year quarterly basis unless agreed upon otherwise The allowable charge for prescription drugs is higher than the price paid to the pharmacy benefit manager 1 for those prescription drugs The Claims Administrator retains the difference and applies it to the cost of operations and the prescription drug benefit program 3.2. Appeals a The Claims Administrator shall review and respond to the initial appeals made by Members of Adverse Benefit Determinations (see section 1)as described in the benefit booklet provided by the Claims Administrator for this Plan The Claims Administrator shall also provide a second review of adverse Member appeal decisions made after its initial review This review will be conducted as described in the benefit booklet provided by the Claims Administrator for this Plan b If an adverse decision on a Member's appeal results from the Plan's internal appeal process,the Claims Administrator agrees to facilitate a review of the appeal by an Independent Review Organization (IRO) on behalf of the Plan Sponsor The Claims Administrator will submit all required documentation regarding the appeal to an IRO and work with the IRO as needed to complete its review The external appeal process for Non-Grandfathered Plans will be offered and administered in accordance with the requirements of the Affordable Care Act The Plan Sponsor is responsible for all costs charged by the IRO to perform its review If the Plan Sponsor chooses to share that cost with Members to the extent allowed under the Affordable Care Act, the Plan Sponsor is responsible to charge and collect any such fee from a Member 3.3. Claims Administrator's Fiduciary Authority The Plan Sponsor and the Claims Administrator agree that the Claims Administrator will have the discretionary authority to administer, process, and determine entitlement to Plan benefits in accordance with the Plan documents for each claim received and to construe the terms of the Plan However, the Plan Sponsor has the sole and complete authority and responsibility to determine eligibility of persons to participate in the Plan It is also agreed that the Claims Administrator has no other discretionary authority under the Plan City of Kent January 1,2012 1018212 3.4. Claims Processing The Claims Administrator shall process all eligible claims incurred after the Effective Date of this Contract which are properly submitted in accordance with the procedures set forth in the Plan Sponsor's benefit booklet The Claims Administrator shall make reasonable efforts to determine that a claim is covered under the terms of the Plan as described in the benefit booklet, to apply the coordination of benefits provisions, and prepare and distribute benefit payments to Members and/or service providers The Claims Administrator shall make reasonable efforts to identify and recover overpayments due to claim processing errors that were within its control, retroactive cancellations, or fraudulent billing practices "Reasonable"for the purposes of this section shall be determined by the Claims Administrator 3.5. Funding Support The Claims Administrator shall follow the steps below to facilitate the Plan Sponsor's funding of its Plan a Claim payment checks will be issued on the Claims Administrator's check stock However, as stated in subsection 2 8 above, the responsibility for funding benefits is the Plan Sponsor's and the Claims Administrator is not acting as an insurer b Each week, the Claims Administrator shall notify the Plan Sponsor of the amount due for the prior week's claims Notice will be by secure e-mail unless another method is agreed upon in writing by the Claims Administrator and the Plan Sponsor 3.6. Annual Accounting Within 120 days of the end of the Contract Period,we shall perform an annual accounting of claims activity and report to the Plan Sponsor 3.7. Participation In Class Action Suits The Plan Sponsor hereby delegates to the Claims Administrator the authority to participate on behalf of the Plan Sponsor, and at the Claims Administrator's sole discretion, in class action lawsuits or settlements regarding any services or supplies covered under the terms of the Plan Examples of such services or supplies include prescription or specialty drugs or medical devices Such participation shall be limited to those instances in which the Claims Administrator determines that it will submit a claim in the subject suit on behalf of its insured book of business The Claims Administrator shall have no obligation to participate on behalf of the Plan Sponsor in any other lawsuit or settlement The Claims Administrator will have no obligation to file claims on behalf of a Plan Sponsor with which the Claims Administrator does not have a contract at the time the claims for recovery are submitted The Plan Sponsor will recover the amount it is due under the terms of the settlement in question based upon the data submitted by the Claims Administrator Any amounts recovered by the Claims Administrator hereunder shall be net of the Claims Administrator's fee as set forth below as well as fees paid to outside counsel in connection with the lawsuit and/or settlement For each class action lawsuit or settlement in which the Claims Administrator participates hereunder on the Plan Sponsor's behalf, the Plan Sponsor shall pay the Claims Administrator a fee representing a proportionate share of a fixed amount intending to compensate the Claims Administrator for its work in connection with pursuing recovery in these cases The fixed amount is shown in"Attachment D—Fees Of The Claims Administrator" This fixed amount is subject to change on an annual basis with at least 60 days' advance notice to the Plan Sponsor The amount of the Claims Administrator's fee payable by each Plan Sponsor shall be based on the proportion of the total amount recovered by the Claims Administrator on behalf of the Plan Sponsor compared to the amount recovered by Claims Administrator for all lines of business The fee will be deducted from the amount of any recovery received on behalf of the Plan Sponsor and will in no event exceed the amount of such recovery Payment hereunder shall be made within 60 days of the Claims Administrator's receipt of the settlement funds The Claims Administrator shall have no obligation to forward settlement funds to any group hereunder if the amount due to the group is less than $5 City of Kent January 1,2012 1018212 The Plan Sponsor may elect to decline to participate in the Claims Administrator's recovery process related to class action lawsuits or settlements regarding any services or supplies covered under the Plan by providing the Claims Administrator written notice Except as set forth below, in the event the Plan Sponsor opts out, the Claims Administrator shall have no further obligation whatsoever to the Plan Sponsor in connection with the recovery process The Plan Sponsor may request that the Claims Administrator gather data necessary for the Plan Sponsor to submit its own claim In any such case, the Plan Sponsor shall pay the amount shown in "Attachment D—Fees Of The Claims Administrator"for the data-gathering services Additionally, the Plan Sponsor shall make any such request in writing a minimum of 30 days in advance of the claim filing deadline 4. LIMITS OF THE CLAIMS ADMINISTRATOR'S RESPONSIBILITY It is recognized and understood by the Plan Sponsor that the Claims Administrator is not an insurer and that the Claims Administrator's sole function is to provide claims administration services and the Claims Administrator shall have no liability for the funding of benefits The Claims Administrator is empowered to act on behalf of the Plan Sponsor in connection with the Plan only as expressly stated in this Contract or as mutually agreed to in writing by the Claims Administrator and the Plan Sponsor This Contract is between the Claims Administrator and the Plan Sponsor and does not create any legal relationship between the Claims Administrator and any Member or any other individual 4.1. Recoveries If, during the course of an audit performed internally by the Claims Administrator as described in subsection 3 1 b above or by the Plan Sponsor pursuant to section 6 below, any error is discovered, the Claims Administrator shall use reasonable efforts to recover any loss resulting from such error 4.2. Independent Contractor The Claims Administrator is an independent contractor with respect to the services being performed pursuant to this Contract and shall not for any purpose be deemed an employee of the Plan Sponsor 4.3. Limits of Liability It is recognized by the parties that errors may occur and it is agreed that the Claims Administrator will not be held liable for such errors unless they resulted from its gross negligence or willful misconduct The Plan Sponsor agrees to defend, indemnify and hold harmless the Claims Administrator from all claims, damages, liabilities, losses and expenses arising out of the Claims Administrator's performance of administration services under the terms of this Contract, so long as they did not arise out of the Claims Administrator's gross negligence or willful misconduct 5. FEES OF THE CLAIMS ADMINISTRATOR 5.1. Payment Time Limits By the first of each month, The Plan Sponsor shall pay the Claims Administrator in accordance with the fee schedule set forth in "Attachment D—Fees Of The Claims Administrator"that is incorporated herein by reference 5.2. Late Payments a If, for any reason whatsoever, the Plan Sponsor fads to make a timely payment required under this Contract by the tenth day of the month in which payment is due, the Claims Administrator may suspend performance of services to the Plan Sponsor, including processing and payment of claims, until such time as the Plan Sponsor makes the required payment, including interest as set forth in c below b In the event of late payment, the Claims Administrator may terminate this Contract pursuant to subsection 9 5 below Acceptance of late payments by the Claims Administrator shall not constitute a waiver of its right to cancel this Contract due to delinquent or nonpayment of fees City of Kent January 1,2012 1018212 c The Claims Administrator will charge interest to the Plan Sponsor on all payments received after the tenth day of the month in which they are due, including amounts paid to reinstate this Contract after termination pursuant to subsection 9 5 below, at the average prime rate posted by Claims Administrator's designated bank during the Contract Period plus two (2) percent on the amount of the late payments for the number of days late Interest will be in addition to any other amounts payable under this Contract 5.3. Customization Fees The Plan Sponsor shall pay the Claims Administrator a"customization fee"when the Plan Sponsor requests either of the following a A plan benefit configuration that the Claims Administrator has not determined to be standard for the plan type Customization fees for nonstandard plan benefits assessed at this Contract's Effective Date are listed in "Attachment D—Fees Of The Claims Administrator" b An off-anniversary benefit change, regardless of whether the desired benefit is standard for the plan type The customization fee for each off-anniversary change shall be$2,000 Customization fees for off- anniversary changes shall be invoiced separately to the Plan Sponsor For purposes of customization fees, "benefits" include eligibility, termination, continuation and benefit payment provisions, benefit terms, limitations, and exclusions, funding arrangement changes, and any other standard provisions of the Plan Fees are computed based on current administrative costs to implement and administer the benefit Customization fees for custom benefits that take effect on the Effective Date shown on the Face Page of this Contract are due and payable prior to that Effective Date Customization fees for off-anniversary benefit changes are due and payable prior to the effective date of the change 6. AUDIT Within thirty(30)days of written notice from the Plan Sponsor,the Claims Administrator shall allow an authorized agent of the Plan Sponsor to inspect or audit all records and files maintained by the Claims Administrator which are directly pertinent to the administration of the Plan for the current or most recently ended contract period Such documents shall be made available at the administrative office of the Claims Administrator during normal business hours The Plan Sponsor shall be liable for any and all fees charged by the auditor All audits shall be subject to the Claims Administrator's audit policies and procedures then in effect To the extent that the Plan Sponsor requests data and reports that are beyond the scope of the Claim Administrator's audit policies and procedures, the Plan Sponsor shall reimburse the Claims Administrator for the additional administrative costs incurred in producing such data and reports Any agent or auditor who has access to the records and files maintained by the Claims Administrator shall agree not to disclose any proprietary or confidential information used in the business of the Claims Administrator 7. SUBROGATION The Claims Administrator shall have no affirmative duty to pursue subrogation claims However,the Claims Administrator may pursue subrogation claims when the Plan Sponsor purchases subrogation services as described in Attachment G—Extended Post-Payment Recovery Services The Plan Sponsor shall have the sole discretion to bring any legal claim or action to enforce the Plan's subrogation provisions The Claims Administrator will cooperate with the Plan Sponsor in the event the Plan Sponsor brings any legal action to enforce the subrogation provisions of the Plan Any costs and attorneys'fees incurred in pursuing such subrogation claims shall be the responsibility of the Plan Sponsor City of Kent January 1,2012 1018212 8. TERM OF CONTRACT 8.1. Contract Period The term of this Contract shall be the Contract Period shown on the Face Page of this Contract Except as stated otherwise in this section and in subsection 8 2 below, the terms and conditions of this Contract and the fee schedule set forth in"Attachment D—Fees Of The Claims Administrator"are established for the Contract Period The Claims Administrator reserves the right to amend this Contract at any time if needed to comply with applicable law or regulation 8.2. Changes to Fees The Plan Sponsor acknowledges that the fee schedule set forth in"Attachment D—Fees Of The Claims Administrator'and the services provided for in this Contract are based upon the terms of the Plan and the enrollment as they exist on the Effective Date of this Contract Any substantial changes, whether required by law or otherwise, in the terms and provisions of the Plan or in enrollment may require that the Claims Administrator incur additional expenses The parties agree that any substantial change, as determined by the Claims Administrator, shall result in the alteration of the fee schedule, even if the alteration is during the Contract Period The phrase"any substantial change"shall include, but not be limited to a, a fluctuation of ten (10) percent or more in the number of Members as set forth on the census information included in"Attachment B—Census Information" which is herein incorporated by reference and made a part of this Contract Termination of Regional Fire Authority (RFA) employees from the plan will not be considered a fluctuation b the addition of benefit program(s)or any change in the terms of the Plan's eligibility rules, benefit provisions or record keeping rules that would increase administration costs by more than$2,000, c any change in claims administrative services, benefits or eligibility required by law, d any change in administrative procedures from those in force at the inception of this Contract that is agreed upon by the parties, e any additional services which the Claims Administrator undertakes to perform at the request of the Plan Sponsor which are not specified in this Contract such as the handling of mailings or preparation of statistical reports and surveys not specified in the Claims Administrator's standard Employer Group Reporting set 9. TERMINATION 9.1. Termination With Notice The Plan Sponsor may terminate this Contract at any time by giving the Claims Administrator thirty(30)days written notice 9.2. Contract Period Expiration This Contract will terminate on the last day of the Contract Period or the last day of any extension of the Contract Period granted by the Plan Administrator 9.3. Termination Due to Insolvency Either party may terminate this Contract effective immediately by giving written notice to the other if a party becomes insolvent, makes a general assignment for the benefit of creditors, files a voluntary petition of bankruptcy, suffers or permits the appointment of a receiver for its business or assets, or becomes subject to any proceeding under any bankruptcy or insolvency law, whether foreign or domestic A party is insolvent if it has ceased to pay its debts in the ordinary course of business, cannot pay its debts as they become due, or the sum of its debts is greater than the value of its property at a fair valuation City of Kent January 1,2012 1018212 9.4. Termination Due to Inability to Perform If loss of services is caused by, or either party is unable to perform any of its obligations under this Contract, or to enjoy any of its benefits because of natural disaster, action or decrees of governmental bodies or communication failure not the fault of the affected party, such loss or inability to perform shall not be deemed a breach The party who has been so affected shall immediately give notice to the other party and shall do everything possible to resume performance Upon receipt of such notice, all obligations under this Contract shall be immediately suspended If the period of nonperformance exceeds thirty(30)days from the receipt of such notice, the party whose performance has not been so affected may,as its sole remedy,terminate this Contract by written notice to the other party effective immediately In the event of such termination, the Plan Sponsor shall remain liable to the Claims Administrator for all payments due, together with interest thereon as provided for in subsection 5 2 c above 9.5. Termination For Nonpayment The Claims Administrator may, at its sole discretion, terminate this Contract effective as of a missed payment due date in the event that the Plan Sponsor fails to make a timely payment required under this Contract 9.6. Plan Sponsor Liability Upon Termination In the event this Contract is terminated prior to the end of the administration fee guarantee period shown in "Attachment D—Fees Of The Claims Administrator,"the Plan Sponsor shall remain liable to the Claims Administrator for all delinquent sums together with interest thereon as provided for in subsection 5 2 c above Furthermore, the Claims Administrator will have incurred fixed costs which, but for the termination, would have been recouped over the course of the administration fee guarantee period Therefore, in the event that the Contract terminates pursuant to subsections 9 1 or 9 5 above,the Plan Sponsor shall also pay the Claims Administrator as liquidated damages, and not as a penalty, an amount equal to two (2) months administration fees This monthly fee shall be determined by multiplying the rate set forth in"Attachment D—Fees Of The Claims Administrator" by the average number of Subscribers covered by the Plan for the immediately preceding six(6) month period or such shorter period if this Contract has not been in effect for a period of six(6) months The liquidated damages amount shall then be reduced on a pro rata basis for the number of months of the administration fee guarantee period that the Contract was in force The Plan Sponsor shall remain liable for claims incurred during the Contract Period but not paid during the Contract Period and for the claims run-out processing fee set forth in the"Fees Of The Claims Administrator" attachment Liquidated damages will not apply in the event Plan Sponsor provides a minimum 12 month notice of its intent to terminate this agreement 9.7. Final Accounting Within one hundred twenty(120)days of termination by either party, the Claims Administrator shall deliver to the Plan Sponsor an interim accounting Within fifteen (15) months of termination the Claims Administrator shall deliver to the Plan Sponsor a complete and final accounting of the status of the Plan At the expense of the Plan Sponsor,the Claims Administrator shall make available a record of deductibles and coinsurance levels for each Member and deliver this information to the Plan Sponsor or its authorized agent 9.8. Claims Runout The Plan Sponsor continues to be solely liable for claims received by the Claims Administrator after the Contract terminates For the fifteen (15)-month period following termination of this Contract, the Claims Administrator shall continue to process eligible claims incurred prior to termination, or adjustments to claims incurred prior to termination, that the Claims Administrator receives no more than twelve(12) months after the date of termination at the claims runout processing fee rate set forth in "Attachment D—Fees Of The Claims Administrator" The runout processing charge will be due in full with the first request for claims reimbursement made during the runout period If the Claims Administrator receives claims for Plan benefits more than twelve(12) months after the date this Contract terminates, Claims Administrator shall deny those claims If the Plan Sponsor wants to negotiate a different arrangement, the Plan Sponsor must contact the Claims Administrator no later than the start of the fourteenth month after the date this Contract terminates City of Kent January 1,2012 1018212 This"Claims Runout"provision shall survive termination of this Contract 10. DISCLOSURE It is recognized and understood by the Plan Sponsor that the Claims Administrator is subject to all laws and regulations applicable to Claims Administrators and health care service contractors It is also recognized and understood by the Plan Sponsor that the Claims Administrator is not acting as an insurer and also is not providing stop-loss insurance 11. OTHER PROVISIONS 11.1. Choice of Law The validity, interpretation, and performance of this Contract shall be controlled by and construed under the laws of the state of Washington, unless federal law applies Any and all disputes concerning this Contract shall be resolved in King County Superior Court or federal court as appropriate 11.2. Proprietary Information The Claims Administrator reserves the right to,the control of, and the use of the words"Premera Blue Cross", "MSC Incorporated as Premera Blue Cross"and all symbols, trademarks and service marks existing or hereafter established The Plan Sponsor shall not use such words, symbols, trademarks or service marks in advertising, promotional materials, materials supplied to Members or otherwise without the Claims Administrator's prior written consent which shall not be unreasonably withheld The Claims Administrator's provider reimbursement information is proprietary and confidential to the Claims Administrator and will not be disclosed to the Plan Sponsor unless and until a separate Confidentiality Agreement is executed by the parties For the purposes of this section, "provider reimbursement information" means data containing, directly or indirectly(a)diagnostic, procedures or other code sets, and (b) billed amount, allowed amount, paid amount or any other financial information for network and non-network hospitals, clinics, physicians, other health care professionals, pharmacies and any other type of facility Such data may or may not specifically identify providers No other provision of this Contract or any other agreement or understanding between the parties shall supersede this provision 11.3. Parties To The Contract The Plan Sponsor hereby expressly acknowledges, on behalf of itself and all of its Members, its understanding that this Administrative Service Contract constitutes a Contract solely between the Plan Sponsor and the Claims Administrator, that the Claims Administrator is an independent corporation operating under a license with the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans (the "Association") permitting the Claims Administrator to use the Blue Cross Service Mark in the States of Washington and Alaska, and that the Claims Administrator is not contracting as the agent of the Association The Plan Sponsor further acknowledges and agrees that it has not entered into this Administrative Service Contract based upon representations by any person other than the Claims Administrator, and that no person, entity or organization other than the Claims Administrator shall be held accountable or liable to the Plan Sponsor for any of the Claims Administrator's obligations to the Plan Sponsor created under this Administrative Service Contract This provision shall not create any additional obligations whatsoever on the Claims Administrator's part other than those obligations created under other provisions of this Administrative Service Contract 11.4. Notice Except for the notice given pursuant to the"Funding"subsection of section 2, any notice required or permitted to be given by this Contract shall be in writing and shall be deemed delivered three (3)days after deposit in the United States mail, postage fully prepaid, return receipt requested, and addressed to the other party at the address as shown on the face page of this Contract or such other address provided in writing by the parties City of Kent January 1,2012 1018212 11.5. Integration This Contract, including any appendices or attachments incorporated herein by reference, embodies the entire Contract and understanding of the parties and supersedes all prior oral and written communications between them Only a writing signed by both parties hereto hereof may modify the terms 11.6. Assignment Neither party shall assign this Contract or any of its duties or responsibilities hereunder without the prior written approval of the other 12. ATTACHMENTS TO THE ADMINISTRATIVE SERVICE CONTRACT The following attach to and become part of the body of this Contract and they are herein incorporated by reference ATTACHMENT B—CENSUS INFORMATION ATTACHMENT B—CENSUS INFORMATION ATTACHMENT C—REPORTING ATTACHMENT D—FEES OF THE CLAIMS ADMINISTRATOR ATTACHMENT E—BUSINESS ASSOCIATE AGREEMENT ATTACHMENT F—CARE FACILITATION ATTACHMENT G—EXTENDED POST-PAYMENT RECOVERY SERVICES ATTACHMENT H—DISEASE MANAGEMENT City of Kent January 1,2012 1018212 i ATTACHMENT A — OUT-OF-AREA SERVICES Premera Blue Cross participates in Inter-Plan Arrangements with other Blue Cross and/or Blue Shield Licensees They include "the BlueCard® Program"and arrangements for payments to non-network providers We are required by the Blue Cross Blue Shield Association (BCBSA) to disclose the information below about these Inter- Plan Arrangements to groups with which we do business The Plan Sponsor has consented to this disclosure to permit us to satisfy our contractual obligations to BCBSA However,this provision defines or modifies the rights and obligations of the parties under this Contract only with regard to the processing of claims for care outside Washington and Alaska or in Clark County,Washington (our"Service Area") Whenever Members access healthcare services outside our Service Area,the claims are processed through one of these Inter-Plan Arrangements and presented to us for payment Payment is made in accordance with the terms and limitations of the Plan and the rules of the applicable BCBSA Inter-Plan Programs policies then in effect Under these policies, we remain responsible to the Plan Sponsor for fulfilling our obligations under this Contract The local Blue Cross and/or Blue Shield Licensee(the"Host Blue") is responsible for such services as contracting and handling substantially all interactions with its network providers When Members are outside our Service Area, they may obtain care from providers that are in the network of a Host Blue or from non-network providers Our payment calculation practices in both instances are described below Circumstances may arise that are not directly covered by this description, however, in those instances, our practices will be consistent with the spirit of this description It is important to note that receiving services through these Inter-Plan Arrangements does not change covered benefits, benefit levels, or any stated residence requirements of the Plan Liability Calculation Method Per Claim Network Providers The calculation of the Member's liability for claims processed through the BlueCard Program will be based on the lower of the network provider's billed charge for the covered services or the allowable charge made available to us by the Host Blue Most often, the Plan Sponsor's liability for those claims is calculated based on the same amount on which the Member's liability is calculated In rare cases,the Plan Sponsors liability may be greater than billed charges if the Host Blue has negotiated with a network provider an inclusive allowance (such as a per-case or per-day amount)for specific services Host Blues may use various methods to determine an allowable charge, depending on the terms of their network provider contracts The allowable charge can be one of the following An actual price An actual price is a priced amount passed to us without any of the adjustments made to estimated or average prices, as explained below An estimated price An estimated price is a negotiated price that is reduced or increased by a percentage to take into account certain payments negotiated with the provider and other claim-and non-claim-related transactions Such transactions may include, but are not limited to, anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific basis, retrospective settlements, and performance-related bonuses or incentives An average price An average price is a percentage of billed charges for the covered services representing the aggregate payments negotiated by the Host Blue with all of its providers or with a similar classification of its providers It may also include the same types of claim-and non-claim-related transactions as an estimated price Host Blues using either an estimated price or an average price may, in accordance with Inter-Plan Programs policies, prospectively increase or reduce such prices to correct for over-or underestimation of past prices Prospective adjustments may mean that a current price reflects additional amounts or credits for claims already paid to providers or anticipated to be paid to or received from providers However, the BlueCard Program City of Kent January 1,2012 1018212 requires that the Host Blue's allowable charge for a claim is final for that claim, no future estimated or average price adjustment will change the pricing of past claims If a Host Blue uses either an estimated price or an average price on a claim, it may also hold some portion of the amount that the Plan Sponsor pays in a variance account, pending settlement with its network providers Because all amounts paid are final, neither variance account funds held to be paid, nor the funds expected to be received, are due to or from the Plan Sponsor Such payable or receivable amounts would be eventually exhausted by provider settlements and/or through prospective adjustments to the negotiated prices Some Host Blues may retain interest earned, if any, on funds held in variance accounts Clark County Providers Some providers in Clark County, Washington do have contracts with us These providers will submit claims directly to us and benefits will be based on our allowable charge for the covered service or supply Non-Network Providers When covered services are provided outside our Service Area by non-network providers, the allowable charge will generally be based on the Host Blue's allowable charge for non-network providers unless a different allowable charge is required by state law Members are responsible for the difference between the amount that the non-network provider bills and this plan's payment for the covered services Exceptions Required By Law Laws in a small number of states may require the Host Blue to include a surcharge as part of the liability for Members'covered services If any state laws mandate other liability calculation methods, including a surcharge, we would then use the surcharge and/or other amount that the Host Blue instructs us to use in accordance with those laws as a basis for determining the plan's benefits and any amounts for which Members are responsible Return of Overpayments Recoveries from a Host Blue or its network providers can arise in several ways Examples are anti-fraud and abuse recoveries, provider/hospital audits, credit balance audits, utilization review refunds,and unsolicited refunds In some cases,the Host Blue will engage a third party to assist in identification or collection of recovery amounts The fees of such a third party may be netted against the recovery Recovery amounts determined in this way will be applied in accordance with applicable Inter-Plan Programs policies, which generally require correction on a claim-by-claim or prospective basis Unless otherwise agreed to by the Host Blue, we may request adjustments from the Host Blue for full refunds from providers due to the retroactive cancellation of membership, but never more than one year after the date of the Inter-Plan financial settlement process for the original claim In some cases, recovery of claim payments associated with retroactive cancellations may not be possible if, as an example, the recovery conflicts with the Host Blues state law or its provider contracts or would jeopardize its relationship with its providers BlueCard Worldwide® If Members are outside the United States, the Commonwealth of Puerto Rico, and the U S Virgin Islands,they may be able to take advantage of BlueCard Worldwide when accessing covered health services BlueCard Worldwide is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico, and the U S Virgin Islands in certain ways For instance, although BlueCard Worldwide provides a network of contracting inpatient hospitals, it offers only referrals to doctors and other outpatient providers Also, when Members receive care from doctors and other outpatient providers outside the United States, the Commonwealth of Puerto Rico and the U S Virgin Islands,the Members will typically have to submit the claims themselves to obtain reimbursement for these services Fees and Compensation Network Providers The Plan Sponsor understands and agrees to reimburse us for certain fees and compensation which we are obligated under applicable Inter-Plan Programs requirements to pay to the Host Blues, to BCBSA, and/or to Inter-Plan Programs vendors, as described below The fees maybe revised in accordance with Inter-Plan Programs standard procedures, which do not provide for prior approval by any plan sponsor Such revisions typically are made annually, but may occur at any time Revisions do not necessarily coincide with the Plan Sponsor's benefit period under this Contract City of Kent January 1,2012 1018212 4 {� a Only the access fee can be charged separately each time a claim is processed If such a fee is charged, it will be either a percentage of the discount/differential we receive from the Host Blue or a set fee, based on the current rate in accordance with the applicable Inter-Plan Program's standard procedures for establishing the access fee rate The access fee will not exceed $2,000 for any claim All other Inter-Plan Programs-related fees are covered by our general administrative fee See"Attachment D— Fees of the Claims Administrator" Non-Network Providers All fees related to non-network provider claims are covered by our general administrative fee City of Kent January 1,2012 1018212 ATTACHMENT B - CENSUS INFORMATION Administration Fees, effective January 1, 2012, are based on the following Number of Active Members: 2247 Employee Spouse Children Medical 805 509 933 Number of COBRA Members: 12 Employee Spouse Children Medical 4 3 5 Number of Retiree Members: 92 Employee Spouse Children Medical 81 11 0 Other Carriers Offered: Group Health Cooperative City of Kent January 1,2012 1018212 4 R E ATTACHMENT C - REPORTING A standard package of reports covering the Contract Period will be provided to the Plan Sponsor within the fees set forth in "Attachment D—Fees Of The Claims Administrator" The reports will cover • Earned premium • Paid claims • Census data • Claims summaries by • Provider type • Service type • Coverage type Please note that reports, format, and content may be modified from time to time as needed City of Kent January 1,2012 1018212 ATTACHMENT D - FEES OF THE CLAIMS ADMINISTRATOR Pursuant to the Administrative Service Contract, the Plan Sponsor shall pay the Claims Administrator the fees, as set forth below,for administrative services Administration Fees: $63 03 per employee per month (without stoploss) $61 03 per employee per month (with stoploss) An additional $2 00 per employee per month administration fee will apply if stoploss coverage is not maintained through LifeWise Assurance Company Administration Fee Guarantee: Year 1/1/2012—1213112012 1/1/2013—12/3112013 1/1/2014—12131/2014 57 00 PEPM (Stoploss not 57 00 PEPM (Stoploss 58 65 PEPM (Stoploss Administration Fee purchased) not purchased) not purchased) $55 00 PEPM (Stoploss purchased) $55 00 PEPM (Stoploss $56 65 PEPM (Stoploss purchased) purchased) Disease Management $4 03 PEPM TBD TBD Brokerage Fee $2 00 PEPM TBD TBD 63 03 PEPM (Stoploss not TBD TBD Total Administration Fee purchased) $61 03 PEPM (Stoploss purchased) Claims Runout Processing Fee: The charge for processing runout claims is an amount equal to the active administration fee at the time of termination, times the average number of subscribers for the 3-month period preceding the termination date, times two Fee For Class Action Recoveries The Plan Sponsor shall pay the Claims Administrator a fee for its work in pursuing class action recoveries on behalf of the Plan Sponsor as described in Subsection "3 7 Participation In Class Action Suits " The fee shall be a proportionate share of$10,000, based on the proportion of the amount recovered on behalf of the Plan Sponsor compared to the total amount recovered by the Claims Administrator for all lines of business BlueCard Fee Amount: BlueCard Fees are tracked and billed monthly in addition to claims expense Care Facilitation: Included in Administration Fee See"Attachment F—Care Facilitation"and "Attachment H—Disease Management'for an overview of services provided City of Kent January 1,2012 1018212 N t Extended Post-Payment Recovery Services: Claims Administrator will perform the services listed below on a pay-for-performance, contingent fee("Contingent Fee") basis, which shall be calculated as a percentage of the gross amount recovered with respect to any particular claim See"Attachment G—Extended Post-Payment Recovery Services"for an overview of services provided Post Payment Recovery Contingent Fee Category Coordination of Benefits 25% Subrogation 25% unless claim requires engagement of outside counsel, in which case the Contingent Fee amount shall be 35% Provider Billing Errors 25% Credit Balance 25% Hospital Billing and Chart Review 35% City of Kent January 1,2012 1018212 ATTACHMENT E - BUSINESS ASSOCIATE AGREEMENT The Plan Sponsor should keep its signed business associate agreement behind this page City of Kent January 1,2012 1018212 ATTACHMENT F - CARE FACILITATION Claims Administrator agrees to provide the following care facilitation programs for the fees shown in "Attachment D—Fees Of The Claims Administrator" Service Description Care Management Prospective and retrospective review for medical Clinical review necessity, appropriate application of benefits Prospective review is not mandatory for provision of benefits Voluntary program to provide cost-effective alternatives for Case management care of complex or catastrophic conditions This service also educates members and assists members and providers in managing breast& lung cancer Includes preventive care programs for members Health Awareness Education immunization reminders, cancer screening reminders, and health education and information Includes provision of evidence-based clinical practice and Quality Programs preventive care guidelines to members and providers, chart tools, and quality of care program activities Prescription drug formulary Development of formulary and access to providers and promotion members on-line Physician-based pharmacy Physician education on cost-effective prescribing management ePocrates Software to provide physicians with up-to-date drug and plan formulary information Education for members using multiple drugs to review Polypharmacy prescriptions with their providers to decrease incidences of adverse drug interactions Follow-up with members and physicians to minimize Point-of-sale Pharmacy inappropriate or excessive drug therapies identified when drugs are dispensed Demand Management Round-the-clock access for members to RNs to answer questions about health care City of Kent January 1,2012 1018212 ATTACHMENT G - EXTENDED POST-PAYMENT RECOVERY SERVICES Claims Administrator, through its affiliate, Calypso, shall provide a set of Extended Post Payment Recovery Services to the Plan Sponsor as described below Claims Administrator will perform these services on a pay-for- performance, contingent fee("Contingent Fee") basis, which shall be calculated as a percentage of the gross amount recovered with respect to any particular claim Contingent Fees are shown in "Attachment D—Fees Of The Claims Administrator" Post Payment Recovery Explanation of Services Category Claims Administrator's investigators and auditors will work to identify and pursue overpayments due to member's missing or inaccurate COB information Claims Administrator utilizes questionnaires and Coordination of Benefits interviews with providers, employers and members to determine if Plan Sponsor's plan is primary or secondary Claims Administrator's investigators, auditors and attorneys identify and pursue overpayments due to Subrogation opportunities Claims Administrator's research to obtain accurate subrogation information and determine group's subrogation rights include questionnaires and interviews with providers, employers and members as well as a review of medical records For verified overpayments Claims Administrator Subrogation manages attorney and member notification,files necessary liens, coordinates case documentation, and provides representation for arbitration hearings The Plan Sponsor will be pre-notified of Claims Administrator's intent to file suit and retains the right to authorize or deny any legal action Claims Administrator's post-payment editing programs and investigators and auditors perform additional screens and tests where billing information is inconsistent with agetservices rendered or where Provider Billing Errors there appears to be up-coding or unbundling of services A recovery process is then employed to request and recover verified overpayments This service requires an on-site review of the provider's financial records and discussions with their staff Credit balances are verified as Credit Balance owed to Plan Sponsor and the source of the credit is determined The credit is reviewed with the provider and approved for payment back to Claims Administrator or the Plan Sponsor This service requires an on-site review of the member's medical charts and interviews with provider staff by registered nurses Calypso out- Hospital Billing and Chart sources the on-site review work to an independent vendor who ensures Review that • Service is consistent with diagnosis and billing is consistent with services City of Kent January 1,2012 1018212 1 Post Payment Recovery Explanation of Services Category • There has been no unbundling of services, diagnosis up-coding or billing maximization • Services rendered were prescribed by the physician and the doctor's notes were signed • Standardized billing and payment policies were used Calypso provides support for this vendor's efforts as well as processes all recoveries i City of Kent January 1,2012 1018212 ATTACHMENT H - DISEASE MANAGEMENT Claims Administrator agrees to make available to the Plan Sponsor certain Disease Management Services as more particularly described in Appendix 1 attached hereto and incorporated herein (the"Services') Claims Administrator, in its sole and absolute discretion, may upgrade or otherwise modify its Services Information and Data For Plan Sponsors for whom the Claims Administrator does not have claims data as it determines necessary for the prior 24-month period, the Plan Sponsor will attempt to obtain such data from the Plan Sponsor's previous health plan(s), 90 days prior to the Plan Sponsor Effective Date The Claims Administrator will cooperate with Plan Sponsor's effort in obtaining such data All such data shall be provided by the Plan Sponsor in a mutually agreeable electronic format Inability to Provide Data. The Parties recognize that the provision of data referenced above is critical to the success of the disease management services Therefore, the Plan Sponsor agrees that if all data referenced above is unavailable or cannot be obtained in a timely fashion, this could, at the Claims Administrator's option, affect the terms, range and availability of Services available to the Plan Sponsor In the event that at least 24 months of historical data is not available, then the Claims Administrator shall adjust reporting and measurement requirements for such Plan Sponsor accordingly General Provisions • The parties understand, acknowledge and agree that the services provided to the Plan Sponsor hereunder are designed for application generally to the entire population of Plan Sponsor members eligible for such services and not for application to each and every such member The Claims Administrator does not represent or warrant that the services provided pursuant to this Attachment will be applied or made with respect to each and every eligible member The Claims Administrator will, however, use commercially reasonable efforts in their attempt to apply such services so that as many eligible members receive such services as appropriate and practicable • Severability In the event that any provision hereof is found invalid or unenforceable pursuant to judicial decree or decision, the remainder of this Attachment shall remain valid and enforceable according to its terms City of Kent January 1,2012 1018212 f Appendix 1 Services Features of the disease management program may include • Integration with medical and behavioral health case management and clinical review services provided by Claims Administrator • Designated clinician will maintain an ongoing relationship with the member • Option for participants who do not want to be contacted by phone to receive information by mail only • Periodic reporting on program enrollment and activities • Addresses certain co-morbidities when they are associated with one or more of the primary conditions Primary Health Conditions The program will focus on the following primary health conditions • Asthma • Chronic Obstructive Pulmonary Disease (COPD) • Coronary Artery Disease(CAD) • Diabetes • Congestive Heart Failure (CHF) s u City of Kent January 1,2012 1018212 40 REQUEST FOR MAYOR'S SIGNATURE KENT Please Fill in All Applicable Boxes W/SHINGTON t Routing Information (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT) Originator: Phone (Originator): Date Sent. _I Date Required- Return Signed Document to CONTRACT TERMINATION DATE: VENDOR NAME: DATE OF COUNCIL APPROVAL,: Brief Explanation of Document: I CiT L- f.A-{2., aF A w ►-I-� P�.�, ��u.� C,es95s. ��c.c�� ►a-PP2�� `Z All Contracts Must Be Routed Through the Law Department (This Area to be Completed By the Law Department) Received: RIC; I V E Approval of City Attorney: I CityAttorney Comments: FEBF 16 2042 KENT ��I I LAW DEPT Date Forwarded to Mayor: I Shaded Areas to Be Completed by Administration Staff �,i Received: I 1 Recommendations & Comments- Disposition: Date Returned: = Iage5870 • 2/04