CLAIM SERVICES. 2.01 Hawaii shall administer all Claims in accordance with the terms and conditions of the C&F Policies, this Agreement, and every applicable code, statute, law, rule, or regulation.
2.02 Hawaii shall perform the Claim Services and refer such Claims as may be designated in accordance with C&F's written standards, limitations, guidelines, instructions, policies, procedures, or limitations provided to Hawaii by C&F from time to time without the need to amend this Agreement.
2.03 Hawaii shall perform the following Claim Services:
A. Examine all reported Claims (including incidents thereof which have been reported but for which no Claims have been made); and
B. Maintain a Claim file for each reported Claim which shall be reviewable at any and all reasonable times by C&F; and
C. Investigate all reported Claims as necessary using (at Hawaii's sole expense), if approved by C&F, a vendor from a list approved in writing by C&F; and
D. Provide C&F, upon request, with a clear synopsis of the fact patterns of any Claim; and
E. Determine and evaluate any coverage issues arising out of or in connection with such Claims, and to refer any actual or potential coverage issues to C&F with recommendations and, thereafter, to follow C&F's direction in the further administration of such Claims; and
F. Prepare and send a reservation of rights letter; and
G. Determine proper workers' compensation benefits due, if any, on compensable Claims; and
H. Establish, pursuant to C&F's standards, reserves for all Claims; and
I. Subject to the limitations contained herein, resist those Claims or adjust, handle, or settle to conclusion those Claims that C&F is legally obligated to pay or which C&F advises Hawaii it desires to pay, including the necessary preparation for and handling of any subrogation or contribution action which may inure to the benefit of C&F; and
J. Make timely payment of Claims and ALAE through C&F's claims system in accordance with payment procedures established by C&F; and
K. Coordinate a proper defense with counsel selected from a defense panel list approved in writing by C&F and reviewed annually with C&F; and
L. Perform all necessary administrative and clerical work in connection with Claims; and
M. Provide all forms necessary for the administration of Claims; and
N. Perform all necessary services to collect Recoveries and properly credit Recoveries to the appropriate Claim file; and
O. Collect, process, and report data in the manner required by the Internal Revenue...
CLAIM SERVICES. The ASO Provider agrees to perform the below enumerated services with respect to the processing and payment of claims under the Plan:
CLAIM SERVICES. Subject to all the terms and conditions of this Agreement, ERS shall provide and shall have the authority and responsibility to provide the following claims adjusting and administration services ("Claim Service(s)") for Client about Claims occurring on and after the Effective Date and ending when the Claims are closed, unless this Agreement is sooner terminated:
(a) Perform the necessary investigation and documentation, including but not limited to Medical Summaries, File Reviews, and adjuster notes, upon which to base a decision regarding liability and damages exposure, secure information required for the adjustment of each Claim, including a Medical Authorization, and provide investigation in the preparation of the defense for Claims which are subject to litigation;
(b) Maintain a list of outside physicians and other specialists for use as necessary in the independent examination and evaluation of all Claims;
(c) Evaluate each Claim with respect to the probable ultimate cost of the Claim, the need for medical management or rehabilitation services for Workers’ Compensation Claims, and such other matters as are routinely evaluated in the industry; provided, that ERS, as it determines necessary in the scope of each Claim, may engage such medical case managers, vocational counselors, independent medical examiners and specialists, to provide opinions with respect to compensability and debatable denials;
(d) Make specific recommendations as to the disposition of the Claim;
(e) Make recommendations, in contested workers’ compensation Claims subject to Iowa law, as to settlement with an Iowa Code §85.35 contested case settlement requiring approval by the Iowa Industrial Commission, or similar procedures as permitted in other applicable jurisdictions
(f) Analyze each Claim to determine Client’s rights against third parties, and, when appropriate, supervise subrogation of Claims on behalf of Client.
(g) Negotiate and settle Claims where appropriate within ERS' judgment and consistent with Section 7 below.
(h) Compute the amount of any loss payments on the Claim, if any payment is warranted, issue such payment and maintain a record of all payments in each Claim file, based upon factual investigation and evaluation of Client’s liability;
(i) With respect to litigated Claims:
(1) Maintain a list of recommended attorneys; provided however, that (i) Client may request the selection of legal counsel other than an ERS recommended attorney; (ii) ERS in no way guarantees o...
CLAIM SERVICES. (A) Aetna shall process claims for Plan benefits incurred on or after the Effective Date using Aetna’s normal claim determination, payment and audit procedures and applicable cost control standards in a manner consistent with the terms of the Plan(s), any applicable provider contract, and the Agreement. Aetna shall issue a payment of benefits and related charges on behalf of the Customer in accordance with section 5 of the Agreement, for such benefits and related charges that are determined to be payable under the Plan(s). With respect to any claims that are denied on behalf of the Customer, Aetna shall notify the Plan Participant of the denial and of the Plan Participant’s right of review of the denial in accordance with applicable law.
(B) Where the Plan contains a coordination of benefits clause or antiduplication clause, Aetna shall administer all claims consistent with such provisions and any information concurrently in its possession regarding duplicate or primary coverage. Aetna shall have no obligation to recover sums owed to the Plan by virtue of the Plan's rights to coordinate where the claim was incurred prior to the Effective Date. Aetna has no obligation to bring actions based on subrogation or lien rights, unless the Customer has elected Aetna’s subrogation services as indicated in the Service and Fee Schedule.
(C) In circumstances where Aetna may have a contractual, claim or payment dispute with a provider, the settlement of that dispute with the provider may include a one-time payment in settlement to the provider or to Aetna, or may otherwise impact future payments to providers. Aetna, in its discretion, may apportion the settlement to self-funded customers, either as an additional service fee from, or as a credit to, the Customer, as may be the case, based upon specific applicable claims, proportional membership or some other allocation methodology, after taking into account Aetna's cost of recovery. The Customer shall remain liable after termination of the Agreement, for their portion of any settlement payments arising from claims paid while an active customer.
CLAIM SERVICES. The Contractor shall process each claim for benefits made by a member on the forms distributed by the State or via State approved electronic means.
CLAIM SERVICES a. Furnish assistance in the development of procedures to be followed for verification of employee and dependent coverage and for submission of claims.
b. Provide standard forms necessary for submission and processing of claims. At the request of Client and at Client's cost, prepare and furnish specially designed claim forms.
c. Evaluate claims submitted, including professional evaluation by the Company's Medical Adjudication Department when required.
d. Compute the amounts of benefits, and prepare and furnish to each Employee a statement of explanation of benefits (EOB).
e. Issue checks in payment of approved claims within a timely manner in compliance with any statutory requirements, to include both state and federal regulations.
f. Maintain and update statistical data that will enable the Client to direct the Company to administer the Plan's "eligible medical expenses" fee basis for benefit payment.
g. Make an examination of charges for medical services that appear excessive and when appropriate, discuss disputed charges for medical services that appear excessive with providers of those services.
h. Provide utilization review for appropriate authorization in connection with the payment of benefits for medical services, if the Plan requires, as a condition of payment.
i. When applicable, determine the amount of Plan benefits payable, if any, when a claimant is eligible for Medicare benefits.
j. Each claim paid by the administrator from money collected for or on behalf of an insurer must be paid by a check or draft upon and as authorized by the insurer. (See NRS 683A.088)
k. Generate 1099 reports to the Internal Revenue Service and send separate statements to providers of medical services furnishing information as required by the Internal Revenue Code and Regulations thereunder regarding amounts paid to these providers of medical services.
l. Maintain levels of claim processing performance in conformance within the following standards:
1. Turnaround time on ninety percent (90%) of all claims not to exceed state law;
CLAIM SERVICES
