Loading...
2004-039 EMI as Third Party Administrator for Health BenefitsRESOLUTION 39-2004 A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF NORTH PALM BEACH, FLORIDA, AUTHORIZING AND DIRECTING THE MAYOR AND VILLAGE CLERK TO ENTER INTO AN ADMINISTRATION AGREEMENT FOR SERVICES WITH EMPLOYERS MUTUAL, INC., ATTACHED AS EXHIBIT "A", WHICH AGREEMENT PROVIDES THAT EMPLOYERS MUTUAL, INC., SHALL PROVIDE THE VILLAGE WITH THIRD-PARTY ADMINISTRATIVE SERVICES FOR THE VILLAGE'S SELF-FUNDED MEDICAL, DENTAL AND FSA PLANS ESTABLISHED FOR VILLAGE EMPLOYEES; AND, PROVIDING FOR AN EFFECTIVE DATE. BE IT RESOLVED BY THE VILLAGE COUNCIL OF NORTH PALM BEACH, FLORIDA: Section 1. The Village Council of the Village of North Palm Beach, Florida, does hereby approve the Administration Agreement for services with Employers Mutual, Inc., attached as Exhibit "A", which agreement provides that Employers Mutual, Inc., shall provide the Village with third-party administrative services for the Village's self-funded medical, dental and FSA plans established for Village employees. Section 2. The Mayor and Village Clerk are hereby authorized and directed to execute the Administration Agreement with Employers Mutual, Inc., attached as Exhibit "A" for and on behalf of the Village of North Palm Beach. Section 3. This resolution shall take effect July 1, 2004. PASSED AND ADOPTED THIS 22nd DAY OF JULY, 2004. „i~uirrnit~t \1 O ~ ~ (~~ i~~~iG ` ,teteetett (:, r, , .' et ~~ i t ~ ; ~ I i' ~ t (V;11a~drS~~i~'~, tF Ott S t. ~° h ` lr ~t°tFrrorrctt SC;~ \~~~ i ~ ~\ ~~~/i.. 1t ~ , , t ,mss ATTEST: VILLAGE EMPLOYERS MUTUAL, INC. ADMINISTRATION AGREEMENT • s~ THIS AGREEMENT is effective this 1 day of July 2004, by and between Village of North Palm Beach, with an address of 501 US Hwy One, North Palm Beach, Florida 33408 hereinafter referred to as the "Plan Sponsor" and EMPLOYERS MUTUAL, INC., a Florida Corporation, hereinafter referred to as the "Contract Administrator". WHEREAS, The Plan Sponsor has established an Employee Benefit Plan, hereinafter called the "Plan", which provides for direct payment of certain health and welfare benefits to and for certain eligible individuals as defined by the Plan's Master Plan Document, such individuals being hereinafter referred to as "Plan Members"; WHEREAS, The .Plan Sponsor desires to engage the services of the Contract Administrator to provide administration services for the Plan; NOW THEREFORE, in consideration of the mutual covenants and conditions as contained herein the parties hereto agree as follows: SECTION I -DUTIES AND RESPONSIBILITIES OF THE CONTRACT ADMI1~tISTRATOR 1.01 The Contract Administrator agrees to perform the following administrative services for the Plan Sponsor: (a) assist in the preparation and printing of a Master Plan Document, or plan booklet, and identification cards, the vendor expense for which shall be billed to the Plan Sponsor on an incurred basis, and other material necessary to the operation of the Plan; (b) process all claims presented for payment, including but not limited to, reasonable investigatory work in determining claim eligibility, noticing initial subrogation intervention, and preparing and distributing benefit checks or drafts to employees and/or service providers; (c) initiate a hospital bill audit for all claims meeting established criteria set forth in Schedule B; (d) answer inquiries from the Plan Sponsor, Plan Members and service providers concerning requirements, procedures or benefits of the Plan; (e) review all applications for coverage under the Plan based upon underwriting guidelines established by the Plan Sponsor, to determine eligibility for status as a Plan Member; (f) maintain all claim files for the Plan; • (g) .prepare and provide to the Plan Sponsor monthly reports of monies received from the Plan Sponsor and all disbursements made to or on behalf of Plan members; (h) provide the Plan Sponsor with a report of the operation of its Plan once a year; and • (i) assist the Plan Sponsor in preparing reports and returns required by any local, state or federal government pertaining to the operation of the Plan. SECTION II -DUTIES AND RESPONSIBILITIES OF THE PLAN SPONSOR 2.01 The Plan Sponsor shall have final authority in determining benefit provisions and Plan language describing such benefit provisions as outlined in the Plan's Master Plan Document and Plan Booklet. 2.02 The Plan Sponsor shall have final authority in determining the eligibility of claims to be paid by the Plan. The Plan Sponsor acknowledges that excess risk insurance coverage purchased by the Plan Sponsor will not provide coverage with respect to any claims not eligible under the express terms and conditions of the Plan. 2.03 The Plan Sponsor shall have final authority in directing the Contract Administrator as to the investment and use of Plan Sponsor assets. 2.04 The Plan Sponsor shall be responsible for collecting all appropriate contributions to pay Plan benefits from all Plan Members in the Plan. Failure to collect any such contributions shall not relieve the Plan Sponsor from its obligation to fund the Plan as required to pay all benefits under the Plan and fees incurred by the Plan. 2.05 The Plan Sponsor shall be responsible for taking the following actions: (a) provide the Contract Administrator with a complete and accurate list of all individuals eligible for benefits under the Plan and who are enrolled in the Plan; (b) notify the Contract Administrator on a timely basis of any changes in eligibility and participation; (c) distribute (and return to Contract Administrator when necessary) to all eligible Plan Members all appropriate and necessary materials and documents, including but not limited to, summary plan descriptions, Plan language amendments, identification cards, enrollment forms, applications and notice forms as may be necessary for the operation of the Plan or to satisfy the requirements of state or federal laws or regulations; (d) satisfy any and all reporting, notice, disclosure, and return requirements imposed by state and federal statutes and regulations upon the Plan; (e) utilize and maintain the Contract Administrator as the single, sole and exclusive contract administrator to assist the Plan Sponsor in administering the Plan; and (f) provide the Contract Administrator with any additional information incidental to the Plan as maybe requested by the Contract Administrator from time to time. SECTION III -FUNDING 3.01 The Contract Administrator shall deposit all monies forwarded by the Plan Sponsor into the Plan Sponsor's account(s). • SECTION IV - ' CONTRACT ADMINISTRATOR S FEES 4.01 The Contract Administrator shall receive consideration in accordance with Schedule A herein incorporated by reference. All monthly fees shall be paid by the 10th day of each month. 4.02 If the Plan Sponsor, for any reason whatsoever, fails to make a required fee payment or necessary contribution for claim payment as requested by the Contract Administrator on a timely basis, the Contract Administrator may suspend the performance of its services to the Plan until such time as Plan Sponsor makes the proper remittance. The Contract Administrator may charge interest to the Plan Sponsor on all past fees due to Contract Administrator at the rate of one and one-half percent (1-1/2%) per month or the maximum rate allowed by law, whichever is less. 4.03 In the event this contract terminates, the Contract Administrator and Plan Sponsor may agree in writing to have the Contract Administrator process the incurred but unpaid claims at such rate as agreed upon. 4.04 Other fees and Commissions- Plan Sponsor agrees that Contract Administrator shall be entitled to receive such commissions as may be payable by reason of Contract Administrator's placement of excess loss insurance (also known as "reinsurance" or "stop loss insurance" with a carver or carriers of such insurance products. Additionally, should Plan Sponsor request Contract Administrator to provide consultation with respect to federal and state guidelines or other areas of expertise, Plan Sponsor agrees to pay to Contract Administrator the hourly rate then currently being charged by Contract Administrator for such consultation services. SECTION V -LIMITS OF THE CONTRACT ADMINISTRATOR'S RESPONSIBILITY 5.01 The Contract Administrator shall have no responsibility, risk, liability or obligation for the funding of Plan benefits. The responsibility and obligation for funding Plan benefits shall be solely and totally the responsibility of the Plan Sponsor. 5.02 Contract Administrator shall be liable for the recovery of claim processing errors arising from the Contract Administrator's performance pursuant to the terms of this Agreement, excepting liability for any such error that is reasonable, made in good faith, and within acceptable industry standards. Contract Administrator shall use diligent efforts toward the recovery of any loss therefrom. Contract Administrator's liability, if any, shall be limited to that amount in excess of the claim amount(s) payable under the terms of the Plan. • 3 5.03 The CONTRACT ADMINISTRATOR agrees to indemnify, defend and hold the PLAN SPONSOR harmless: (a) for any penalty or fine the plan sponsor shall suffer that is solely the fault of the • Contract Administrator; (b) for any claim payment or premium payment that is made in error provided the amount paid in error is not recoverable through normal procedures and provided it was within the Contract Administrator's ability to discover the error using a standard of care reasonable under the circumstances; (c) for any claims resulting from errors, omissions or negligence on the part of the Contract Administrator, unless the actions of the Contract Administrator were taken at the direction of the plan sponsor or as the result of the Plan Sponsor's negligence. The PLAN SPONSOR agrees to indemnify, defend and hold the CONTRACT ADMINISTRATOR harmless: (a) for any and all claims that arise out of this contract in the event of an adverse result or judgement, if the Contract Administrator is not guilty of error that could have been discovered using a standard of care reasonable under the circumstances; (b) for any action resulting from the Contract Administrator acting at the direction of the Plan Sponsor in the event the Contract Administrator becomes liable to any third parties; (c) for any action resulting from a cause of action involving a claim covered under the Plan Sponsor's insurance program where the Contract Administrator is providing the services specified under this contract. 5.04 It is understood and agreed that the Contract Administrator is not a fiduciary to the Plan. Notwithstanding anything in the Agreement to the contrary any delegation of authority or duties pursuant to this Agreement construed by a court of law or governmental agency to make the Contract Administrator a fiduciary shall be null and void, and such duties are hereby retained by the Plan Sponsor. 5.05 In any litigation between the parties in regards to this agreement, the prevailing party in such litigation shall be entitled to recover from the non-prevailing party a reasonable attorney's fees and all costs of litigation both at the trial and appellate level. SECTION VI -PROVIDER NETWORK 6.01 The membership of the Sponsor's Plan are to receive health care delivery through EMI's contracted provider network for which "access" is contracted. • 4 6.02 The Plan Sponsor or the Contract Administrator may negotiate the provider network contract with both parties being knowledgeable of the terms of the fee(s) to be paid for the • network "access" privilege. 6.03 The Contract Administrator will maintain records of the contracted providers on its claims processing system files. 6.04 The Contract Administrator will maintain records of the negotiated claims payment allowances for the contracted providers within the network. SECTION VII -OUT OF NETWORK SERVICES 7.01 The Contract Administrator may at its discretion, negotiate reduced billings from hospitals, physicians and ancillary providers in the instance of allowable services performed outside the provider network contracted for health care delivery to the Plan membership. However, the Contract Administrator shall have no affirmative duty to negotiate the billing reductions except as provided under Section 1.01. 7.02 All expenses and fees incurred in the provider fee negotiations shall be deducted from the billed charges savings. The Contract Administrator will be entitled to 15% of the negotiated savings. 7.03 The Contract Administrator is authorized to negotiate and remit payments of the billable charges and other incurred expenses and fees. SECTION VIII -UTILIZATION MANAGEMENT SERVICES 8.01 Management Services. The function of these services is to make recommendations as to whether specific health care services are covered by the plan, that proposed treatment is consistent with industry standard protocols and is medically necessary as defined under the Plan Document. The utilization management service does not determine what medical treatment shall be provided to the patient. The Contract Administrator agrees to perform the following Utilization Management Services for the Plan Sponsor: (a) Pre-Certification. Plan Administrator will prospectively review the medical necessity of scheduled hospital admissions, contemplated surgical procedures and other health care services as required in the Plan Document. The pre-certification process will review Provider's and Patient's plans for care. Second medical opinions will be recommended when medical necessity appears uncertain. This pre-certification process will also review surgical necessity and proposed length of stay. Pre-Certification shall initially be conducted by the Plan Administrator's • Utilization Management Nurse who will advise the physician and patient whether the pending admission or surgical treatment is medically necessary as defined under the Plan and, if so, the recommended length of stay for the specific 5 diagnosis or procedure involved. In now event shall any such recommendation be construed as precluding any health care service. The decision for admission shall be the sole responsibility of the patient and the patient's physician. • (b) Concurrent Review. Contract Administrator shall review and monitor emergency hospital admissions and ongoing hospital confinements to make recommendations concerning the medical necessity of continuing inpatient care. (c) Discharge Planning. Contract Administrator will consult with the patient attending physician(s) and hospital to assure that discharge planning is conducted on a timely basis, recommending less intensive settings for care and treatment when appropriate. (d) Case Management. Contract Administrator shall provide Case Management services to assist patients in the coordination and administration of health care in the treatment and care of long-term or terminal illness and serious injuries requiring extended care. Contract Administrator will identify potential cases for Case Management based on the severity of diagnosis. This program utilizes an interactive approach involving the case manager, attending physician, hospital, patient and the patients family. (e) MedicaUPeer Review Consultations. The Contract Administrator Utilization Management Department may utilize the services of a peer review physician for review of medical records as the final process of a request for appeal. Charges incurred as a result of these reviews will be billed to the patients claim file. SECTION IX -COBRA 9.01 Contract Administrator will provide the following COBRA non-discretionary, ministerial record-keeping and notification services on behalf of the employer: (a) Generate and send employer a monthly bill for COBRA services. (b) Generate and send COBRA notice and election form to Qualified Beneficiaries (QB's) immediately following a Qualifying Event. (c) Generate and send monthly bills to QB's. (d) Provide telephonic support for QB's (regarding eligibility, billing issues, etc.). (e) Process premiums. (~ Communicate eligibility of QB's to carriers. (g) Generate and send reports to carriers. • 6 SECTION X -HIPAA 10.01 Contract Administrator qualifies as a business associate of the Plan Sponsor, as defined in Title 45 Code of Federal Regulations Section 160.103, the Administrative Simplification . provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Contract Administrator agrees to perform its responsibilities called for under this Agreement in a manner which complies with the requirements of HIPAA then in effect and as applicable to Contract Administrator. Further, Contract Administrator specifically agrees to the following requirements: (a) Contract Administrator shall not use or further disclose individually identifiable personal health information other than is permitted by this Agreement or as authorized by law; (b) Contract Administrator shall use appropriate safeguards to prevent unauthorized uses or disclosures of individually identifiable personal health information and report any such disclosure to the Plan Sponsor; (c) Contract Administrator shall ensure that its employees, agents, contractors and representatives agree to comply with the foregoing requirements. Contract Administrator shall take immediate corrective action against any of its employees, agents, contractors or representatives who use or disclose individually identifiable personal health information in violation of this Agreement; (d) Contract Administrator agrees that the remedy for a violation or breach of this Agreement shall include equitable relief, and that Plan Sponsor may seek to enjoin the unauthorized disclosure or seek affirmative relief requiring the return or destruction of individually identifiable personal health information in the possession or custody of Contract Administrator, its employees, agents, contractors or representatives or other third parties persons not authorized to such possession or custody. SECTION XI -SUBROGATION 11.01 The Contract Administrator may at its discretion, pursue subrogation rights on behalf of the Plan Sponsor or may contract with a third party to pursue such rights of recovery. However, the Contract Administrator shall have no affirmative duty to pursue, or to contract with any third party to pursue, such rights of subrogation except as provided under Section 1.01 (b). The Plan Sponsor shall cooperate with the Contract Administrator or any such third party subrogation contractor in the recovery effort. 11.02 All costs and fees incurred in connection with any subrogation action shall be paid out of any recoveries. • 11.03 Contract Administrator, or any third party subrogation contractor, is authorized to negotiate and settle all subrogation actions. • SECTION XII -RECORDS 12.01 During the term of this agreement, Contract Administrator shall maintain all records and files in conjunction with the administrative services to, be performed hereunder. All records and files generated are, and will remain, the property of the Plan Sponsor. The term "records and files" shall mean the claim files, unissued and canceled checks, bank statements, enrollment cards, copies of reinsurance applications and contracts, copies of the account ledger sheets of any Plan account(s), and copies of any computer records. 12.02 The Plan Sponsor shall not have access to any records containing personal information, unless appropriate releases and authorizations are presented to the Contract Administrator. Personal information includes, but is not limited to, medical record information as well as any other individually identifiable information gathered in connection with a benefit transaction. 12.03 The Contract Administrator shall within thirty (30) days written notice from the Plan Sponsor, allow the Plan Sponsor or an authorized agent to inspect or audit all records and files maintained by the Contract Administrator at the administrative office of the Contract Administrator during normal business hours. The Plan Sponsor shall be liable for any and all fees to be charged by the auditor. Any such agent or auditor that has access to the records and files maintained by the Contract Administrator shall agree not to disclose any proprietary and confidential information used in the business of the Contract Administrator. SECTION XIII- DISCLOSURE 13.01 It is recognized and understood by the Plan Sponsor that the Contract Administrator is not an Insurance company. 13.02 It is recognized and understood by the Plan Sponsor that the Contract Administrator is subject to all laws and regulations applicable to contract administrators. 13.03 It is recognized and understood by the Plan Sponsor that the Contract Administrator may provide a hospital bill audit service itself or through a designated agent. Contract Administrator or its agent may receive a percentage of any reduction in claim amount(s), after costs, resulting from the hospital review bill process. SECTION XIV- TERM OF AGREEMENT 14.01 This Agreement shall become effective at 12:01 a.m. on the 1S` day of July 2004 and shall remain in effect until terminated pursuant to Section XV of this Agreement. The aforementioned effective date, and each annual effective date anniversary, shall also be • known as the Plan's "Anniversary Date". 8 SECTION XV -TERMINATION 15.01 It is understood and agreed that either party shall have the right to terminate this agreement on any Anniversary Date by: (a) the Plan Sponsor giving the Contract Administrator not less than sixty (60) days advance written notice of termination. (b) the Contract Administrator giving the Plan Sponsor not less than sixty (60) days advance written notice of termination. 15.02 Contract Administrator may, at its sole discretion, terminate this agreement in the event that the Plan Sponsor fails to properly fund the Plan within fifteen (15) days of receiving a written request to do so from the Contract Administrator. 15.03 Upon termination by either party, the Contract Administrator shall, within ninety (90) days of the termination of services under this agreement, deliver to the Plan Sponsor a complete and final accounting of the financial status of the Plan. Contract Administrator shall, upon the request and at the expense of the Plan Sponsor, provide computer runs detailing various aspects of Plan Sponsor's Plan. Upon termination, the Plan Sponsor understands and agrees that, except where there is evidence of gross negligence or willful misconduct or fraud, the Contract Administrator is released from all liability, loss, or damage arising in any manner out of the Plan or its administration or the performance by Contract Administrator pursuant to the terms of this Agreement. 15.04 It is understood that at termination of this Agreement, the Contract Administrator shall process incurred-but-not-reported and not previously processed claims of "run-out" at a fee mutually agreed upon by Plan Sponsor and Contract Administrator. 15.05 All notices or other communications required by this section shall be effective upon deposit with the United States Postal Service for delivery by certified mail; return receipt requested. SECTION XVI -BONDING 16.01 The Contract Administrator shall, within thirty (30) days of the receipt of a written demand, present evidence to the Plan Sponsor that its employees are fully bonded as required by state and federal statutes and regulations. SECTION XVII -MISCELLANEOUS PROVISIONS 17.01 If any provision of this Agreement is held invalid or unenforceable, such invalidity or unenforceability shall not affect any other provision, and this Agreement shall be construed and enforced as if such provision had not been included. • 17.02 This Agreement may be amended by Plan Sponsor and Contract Administrator at any time by mutual written consent of both parties. No amendment, under any circumstances, may reduce any benefit which might be paid for any cause prior to the amendment or prejudice a • claim. 17.03 Plan Sponsor is hereby designated as agent for service of legal process on behalf of the plan at its principal office. 17.04 It is understood that Contract Administrator will from time to time take advantage of processing efficiencies through system developments of communication and/or interface with other systems or via the Internet. It is further understood that these improved system capabilities of data base interrogation, file maintenance or claims processing will be offered to the Plan Sponsor at a negotiated fee. 17.05 It is understood and agreed that Plan Sponsor is the named Plan Administrator within the meaning of Section 414(g) of the Internal Revenue Code of 1986, as amended, and is the named Administrator within the meaning of Section 3(16)(A) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended. 17.06 This Agreement is the entire agreement of the parties and supersedes all prior contracts, representations, understandings, memoranda and other communications between the parties. SECTION XVIII -INSURANCE CLAUSES 18.01 The Contract Administrator shall maintain, or cause to be maintained, the following specified insurance coverages in the amount set forth hereafter. (a) Workers Compensation: Coverage to apply for all employees for Statutory Limits in compliance with the applicable State and Federal laws. The policy shall include Employers Liability. Notwithstanding the number of employees or any other statutory provisions to the contrary, coverage shall extend to all employees of the Contract Administrator. Statute limits shall be in compliance with applicable State and Federal laws. (b) Comprehensive General Liability: Shall have the minimum limits of $1,000,000.00 Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property Damage Liability. This shall include Premises and Operations, Independent Consultants, Products and Completed Operations, Broad Form Property/Personal Injury, XCU coverage, and a Contractual Liability Endorsement. (c) Business Auto Liability: Shall have the minimum limits of coverage of $500,000 Per Occurrence, Combined Single Limit for Bodily Injury and Property Damage Liability. This shall be an any-auto policy including Owned, Hired, Non-Owned, and Employee Non-Ownership Coverage. • 10 (d) Professional Liability: Insurance and Indemnification- The Contract Administrator shall maintain Professional Liability Insurance covering the Contract Administrator for sums which the Contract Administrator shall become legally obligated to pay as • damages because of liability arising out of any negligence, error or mistake in rendering or omission in failing to render the professional services required in the performance of the Contract Administrator's agreement with the Plan Sponsor. Required coverage shall be for Limits of Liability not less than $1,000,000.00. SECTION XIX -ATTACHMENTS TO THE ADMINISTRATION CONTRACT 19.01 The following list of Schedules attach to and become part of the body of this contract and are herein incorporated by reference when selected by the Plan Sponsor as part of the administrative services to be performed by the Contract Administrator. ^ FEE SCHEDULE - Schedule A ^ HOSPITAL BILL AUDIT CRITERIA -Schedule B PLAN SPONSOR CONTRACT ADMINISTRATOR VILLAGE OF NORTH PALM BEACH EMPLOYERS MUTUAL, INC. By Name ~,4l~~ ~: /1~D~/ Name: Clark Palmer Title: ~,~ I/~/2 Date: 7~.~2~~D GL ATTEST: ~ ~ i VILLAGE CLERK u Title: CFO Date: ~ ~ ~~7' 11 SCHEDULE A -FEE SCHEDULE THIS SCHEDULE is effective from the 151 day of July 2004, through the 30"' day of June 2005, • by and between VILLAGE OF NORTH PALM BEACH, with an address of 500 US Hwy One, North Palm Beach, Florida 33408, referred to as "Plan Sponsor" and EMPLOYERS MUTUAL, INC., referred to as "Contract Administrator". This Schedule supplements the Administration Agreement by and between Plan Sponsor and Contract Administrator effective the 15` day of July 2004. Pursuant to the Administration Agreement, Plan Sponsor shall provide to Contract Administrator the following administrative fees and other costs for the Plan Year beginning the 15` day July 2004. FEE S PER EMPLOYEE PER MONTH Claims Administration: $14.00 (includes Utilization Management, Case Management, COBRA, and HIPAA) EMI/Dimensions Plus Network Administration Fees: $4.50 Beechstreet Wrap-Around 20% of savings Flexible Spending Accounts Administration $4.25 Renewal Increase: The above fees are based on a 12-month guarantee, after the 12 month period EMI guarantees that the fees will not exceed more than 5% annually for years 2 and 3. The Contract Administrator cannot guarantee the network access fee increases. Additional Services Not Covered Above If additional services/projects are requested by Plan Sponsor, and Contract Administrator agrees to deliver additional services/projects, then the fee for these additional services/projects will be computed based upon the time and materials needed to deliver those additional services/projects. Printing & mailing costs for provider directories, Summary Plan documents, outsourced ID card production and similar items will be a pass through cost at the expense of the Plan Sponsor and aze not included in the fees above. The cost to develop a complete ad hoc report package customized to the Plan Sponsor needs will be computed based upon the time, complexity and programming needed to deliver these reports. The fee for developing and maintaining any data interchanges and interfaces, e.g., eligibility to pharmacy vendors, networks, positive pay bank interfaces are not included in the fees above. Upon request from the Plan Sponsor to provide any of these additional services/projects or materials, Contract Administrator will develop a budget and obtain prior written consent of the Plan Sponsor before proceeding. 12 SCHEDULE B -HOSPITAL BILL AUDIT CRITERIA • Internal Audit Procedure- (a) Identification of claims in excess of $25,000: All claims payments of $10,000 or more are referred to the Claims Manager for internal review and signature. Claims Manager will submit the claims payments exceeding $25,000 for further in-house review and if necessary refer to an outside audit firm. (b) Claim Audit: Claims Manager has the responsibility to ensure that the claim is appropriately audited. He/she will also confirm that any corrective action has been taken on any errors identified in the course of the audit. The following criteria is measured during the audit: Employee Eligibility/Dependent Eligibility Deductibles (Single or Family) Coinsurance Policy Maximum Cost Containment Provider Data Covered Expense Coordination of Benefits Data Entry Claim Administrative Procedure Missing Documentation (c) Sign-off: Upon completion of the audit, and statement of corrective action taken, VP- COO will sign-off. (d) Outside Audit: If the Claims Adjuster, Claims Manager or Utilization Manager feel the provider is imJ properly billLing, the cla~i{m is referred to an outside/ audit firm. 7,tL..' Q~?c~/~.~ .`- ci T` c~. -'~} ~'= `l > i-~i { LCL'~ ~` iJ_ ~= '/~/• "~,! ~ f9~'~~y cy'/~~ 9 • 13 SCHEDULE B -HOSPITAL BILL AUDIT CRITERIA • Internal Audit Procedure- (a) Identification of claims in excess of $25,000: All claims payments of $10,000 or more are referred to the Claims Manager for internal review and signature. Claims Manager will submit the claims payments exceeding $25,000 for further in-house review and if necessary refer to an outside audit firm. (b) Claim Audit: Claims Manager has the responsibility to ensure that the claim is appropriately audited. He/she will also confirm that any corrective action has been taken on any errors identified in the course of the audit. The following criteria is measured during the audit: Employee Eligibility/Dependent Eligibility Deductibles (Single or Family) Coinsurance Policy Maximum Cost Containment Provider Data Covered Expense Coordination of Benefits Data Entry Claim Administrative Procedure Missing Documentation (c) Sign-off: Upon completion of the audit, and statement of corrective action taken, VP- COO will sign-off. (d) Outside Audit: If the Claims Adjuster, Claims Manager or Utilization Manager feel the provider is improperly billing, the claim is referred to an outside audit firm. • 13 a 4~,G,u~ t~~ CDP,ftt ~o uctt~el6 ~C.~r~ ~~04~ July 2, 2004 Village of North Palm Beach Attn: Shaukat Khan 501 US Hwy One North Palm Beach, FL 33408 Dear Shaukat, Enclosed please find two signed original copies of the Administrative Services Agreement between Village of North Palm Beach and Employers Mutual Inc. We received the fax request for changes from George Baldwin Esq. on June 28, 2004. All of the requested changes or additions have been made with the exception of adding the Village as an insured under our General Liability and Automobile Liability policy. It is not EMI's practice to include any client as named insureds under these insurance polices. In addition, we removed the last statement under Professional Liability; $5,000 is not an obtainable amount in the market place. Please contact our office should you have any questions or need any additional information. Sincerely, ~j ~j~ ~ ,~ athleen Barry Ext 4473 • LEE COUNTY JACKSONVILLE STUART 2055 Central Avenue 1000 Riverside Avenue, Suite 400 700 Central Parkway Ft. Myers, Florida 33901 acksonville, Florida 32204 ~ Stuart, Florida 34994 772.287.7650 239.337.8133 • Fax: 239.337.8666 800.697.2235 • Fax: 904.598.5288 800.431 .2221 Fax: 772.287.1387 Visit us at www.emi-tpa.com Visit us at www.emitpa.com Visit us at www.emi•cpa.com Employers Mutual, Inc.