CLAIM FILING AND PROVIDER PAYMENTS This section provides information regarding how a member may file a claim for a covered healthcare service and how we pay providers for a covered healthcare service. How to File a Claim Network providers file claims on your behalf. Non-network providers may or may not file claims on your behalf. If a non-network provider does not file a claim on your behalf, you will need to file it yourself. To file a claim, please send us the provider’s itemized bill, and include the following information: • your name; • your member ID number; • the name, address, and telephone number of the provider who performed the service; • date and description of the service; and • charge for that service. Please send your claim to the address listed in the Contact Information section. Claims must be filed within one calendar year of the date you receive a covered healthcare service. Claims submitted after this deadline are not eligible for reimbursement. This timeframe does not apply if you are legally incapacitated. How Network Providers Are Paid We pay network providers directly for covered healthcare services. Network providers agree not to bill, charge, collect a deposit from, or seek reimbursement from you for a covered healthcare service, except for your share under the plan. When you see a network provider, you are responsible for a share of the cost of covered healthcare services. Your share includes the deductible, if one applies, and the copayment, as listed in the Summary of Medical Benefits. The covered healthcare service may also have a benefit limit, which caps the amount we will reimburse the provider for that service. You will be responsible for any amount over the benefit limit, up to the allowance. Your provider may request these payments at the time of service, or may bill you after the service. If you do not pay your provider, the provider may decline to provide current or future services or may pursue payment from you, such as beginning collection proceedings. Some of our agreements with network providers include alternative payment methods such as incentives, risk-sharing, care coordination, value-based, capitation or similar payment methods. Your copayments are determined based on our allowance at the date the service is rendered. Your copayment may be more or less than the amount the network provider receives under these alternative payment methods. Your copayment will not be adjusted based on these alternative payment methods, or for any payment that is not calculated on an individual claim basis. Our contracts with providers may establish a payment allowance for multiple covered healthcare services, and we may apply a single copayment based on these arrangements. In these cases, you will typically be responsible for fewer copayments than if your share of the cost had been determined on a per service basis.
Certification for Federal-Aid Contracts Lobbying Activities A. The CONSULTANT certifies, by signing and submitting this Contract, to the best of its knowledge and belief after diligent inquiry, and other than as disclosed in writing to the LPA prior to or contemporaneously with the execution and delivery of this Contract by the CONSULTANT, the CONSULTANT has complied with Section 1352, Title 31, U.S. Code, and specifically, that:
Annexes and Protocols The Annexes and the Protocols to this Agreement are an integral part of it. The Joint Committee may decide to amend the Annexes and Protocols.
ATTACHMENT E BUSINESS ASSOCIATE AGREEMENT This Business Associate Agreement (“Agreement”) is entered into by and between the State of Vermont Agency of Human Services, operating by and through its Department of Vermont Health Access (“Covered Entity”) and OptumInsight, Inc. (“Business Associate”) as of June 6, 2014 (“Effective Date”). This Agreement supplements and is made a part of the contract/grant to which it is attached. Covered Entity and Business Associate enter into this Agreement to comply with standards promulgated under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), including the Standards for the Privacy of Individually Identifiable Health Information, at 45 CFR Parts 160 and 164 (“Privacy Rule”), and the Security Standards, at 45 CFR Parts 160 and 164 (“Security Rule”), as amended by Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH), and any associated federal rules and regulations. The parties agree as follows:
DATA BREACH - REQUIRED CONTRACTOR ACTIONS Unless otherwise provided by law, in the event of a Data Breach, the Contractor shall:
Customer Cooperation 3.2.1. Customer shall provide and make available all Customer personnel as may be further addressed in an applicable Order Form or that SAP reasonably requires in connection with performance of the Services.
Operating and Maintenance Manuals 58.1 If “as built” Drawings and/or operating and maintenance manuals are required, the Contractor shall supply them by the dates stated in the Contract Data.
Operation and Maintenance Manuals Receipts for transmittal of Operation and Maintenance Manuals, Brochures and Data to the Design Professional (or Commissioning Agent) as required by Section 6.1.1.5.
Ordering and Provisioning 53.1 National Exchange Access Center (NEAC)
Obligations of Business Associate Upon Termination Upon termination of this Agreement for any reason, business associate shall return to covered entity or, if agreed to by covered entity, destroy all protected health information received from covered entity, or created, maintained, or received by business associate on behalf of covered entity, that the business associate still maintains in any form. Business associate shall retain no copies of the protected health information.
