Claim Audits Sample Clauses

Claim Audits. The Employer may request, and PBA shall cooperate with, an audit of Plan records of claim payments and denials for the purpose of evaluating claim processing accuracy by PBA. Such request must be made in writing to PBA at least twenty-one days prior to scheduling the audit in order for PBA to retrieve records and provide for adequate audit support. The Employer and PBA shall mutually agree on the appointment of any independent third party auditors at least fourteen (14) days prior to the audit. PBA shall have the right to refuse to cooperate with a third party auditor operating on a contingency fee basis. The Employer agrees to bear the cost of any extraordinary expenses incurred by PBA as a result of such audit. The Employer and PBA agree that claim processing accuracy will be evaluated based upon a reasonable selection of claim records by the Employer. PBA shall have the right to contest any audit findings for which it can demonstrate a basis within generally accepted industry standards. PBA shall promptly adjust any claims that are found to be underpaid during the term of this Agreement. PBA shall make reasonable efforts during the term of this Agreement to recover any payments that are found to be overpaid. PBA shall not be held liable for such recoveries; nor shall PBA be responsible for refunding the Plan for overpaid claim amounts.

Claim Audits a. Claim Audit. Employer may, audit CHLIC's payment of Plan Benefits in accordance with the following requirements: i. Employer shall provide to CHLIC a scope of audit letter and the fully executed Claim Audit Agreement, a sample of which is attached hereto as Exhibit C together with a forty-five (45) day advance written request for audit. ii. Employer may designate with CHLIC's consent (which consent shall not to be unreasonably withheld) an independent, third-party auditor to conduct the audit (the "Auditor"). iii. Employer and ▇▇▇▇▇ will agree upon the date for the audit during regular business hours at CHLIC's office(s). iv. Except as otherwise agreed to by the parties in writing prior to the commencement of the audit, the audit shall be conducted in accordance with the terms of CHLIC's Claim Audit Agreement attached hereto as Exhibit C, which is hereby agreed to by Employer and which shall be signed by the Auditor prior to the start of the audit. v. If the audit identifies any claim adjustments, such adjustments will be made in accordance with this Agreement and based upon the actual claims reviewed and not upon statistical projections or extrapolations. vi. Employer shall be responsible for its Auditor’s costs. Employer may (as determined by CHLIC based upon the resources required by the audit requested) be responsible for CHLIC's reasonable costs with respect to the audit, except that while this Agreement is in effect there shall be no additional cost to Employer for an audit of payment documents (subject to any contrary terms in Participating Provider agreements) relating to a random, statistically valid sample of two-hundred twenty-five (225) claims paid during the two prior Plan years and not previously audited, provided that if Employer has five thousand (5,000) or more employee who are Members, Employer may conduct one such audit every Plan Year (but not within six (6) months of a prior audit); otherwise, Employer may conduct one such audit every two (2) Plan Years (but not within eighteen (18) months of a prior audit). In no event shall any audit involve Plan benefit payments made prior to the most recent two

Claim Audits. (i) Upon Sponsor’s written authorization, ESI will provide de-identified claims data in a file layout acceptable to Aon ▇▇▇▇▇▇ or Sponsor’s auditor to perform a claims audit. (ii) Aon ▇▇▇▇▇▇ or Sponsor, or a mutually acceptable independent third party retained by Aon ▇▇▇▇▇▇ or Sponsor, may conduct a claims audit annually and such audits shall not exceed twenty-four (24) months immediately preceding the request to audit.