Claims Administrator A. The Human Resources Director through his/her designated Claims Administrators shall administer the provision of this policy. The City Physician shall provide the City's Claims Administrators with all available medical information concerning the Employee's injury and/or medical opinions as requested. Medical information and opinions shall be based upon the Employee's medical records and/or physical examination. Questions of Employee eligibility shall be determined by the provisions established under State Statute 49-110, 49-111 and Oklahoma Worker's Compensation Title 85. Prior to any denial of injury leave benefits where lost time actually occurred, the administrator shall notify Union and allow a Union representative the opportunity to review the application pending denial and provide any additional information relating to same as may be necessary. Should the City change designated Claims Administrators Local 176 will be notified in writing.
Claims Administration An employee will be required to comply with any and all rules and regulations and/or limitations established by the carrier or applicable third party administrator and contained in the policy, and employees and their dependents shall look solely to such carrier or third party administration for the adjudication of the payment of any and all benefits claims.
Claims Review Population A description of the Population subject to the Claims Review.
Claims Review Methodology a. C laims Review Population. A description of the Population subject to the Quarterly Claims Review.
Plan Administrator Employees must elect a plan administrator during their initial enrollment in Advantage and may change their plan administrator election only during the annual open enrollment and when permitted under Section 5. Dependents must be enrolled through the same plan administrator as the employee.
Review Protocol A narrative description of how the Claims Review was conducted and what was evaluated.
Claims Review Report The IRO shall prepare a Claims Review Report as described in this Appendix for each Claims Review performed. The following information shall be included in the Claims Review Report for each Discovery Sample and Full Sample (if applicable).
Separate Grievance File All documents, communications and records dealing with the processing of a grievance shall be filed in a separate grievance file and shall not be kept in the personnel file of any of the participants.
Claims Review The IRO shall perform the Claims Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each Claims Review.
Claims Review Objective A clear statement of the objective intended to be achieved by the Claims Review.
