CLAIMS AUDIT. The Board shall cause a biannual claims audit of the administration of the claims for each of the Programs of PARSAC. A report of such claims review shall be made available for inspection by the Board and the Member Entities. PARSAC shall pay all costs of such claims reviews.
CLAIMS AUDIT. The Company and the Reinsurer may, at any time, elect to appoint an independent auditor. This appointment shall be subject to approval by the Reinsurer. Upon approval, the Reinsurer agrees to pay its proportionate share of the cost of such audit as well as its proportionate share of the final claim. In the event that a claim may be recoverable hereon and the Company does not elect to appoint an independent auditor, the Reinsurer reserves the right to appoint an independent auditor to investigate the potential claim. Should the Reinsurer appoint an independent auditor, all costs of this audit shall be borne by the Reinsurer. The Company agrees that the amount of any claim subsequently recovered upon shall be based entirely on the audited figures irrespective of whether or not the independent auditor has reduced the initial claim.
CLAIMS AUDIT. For the purpose of claims audit, the NHA may constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims recommended for rejection or partially processed by the ISA or partially settled by NHA to assure itself of the legitimacy of the ISA’s decisions. Claims settlement decisions of the ISA that are disputed by the concerned HCP shall be examined in depth by the CRC after such grievance of the HCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the HCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the NHA shall look into the following aspects (indicative, not exhaustive): • Evidence of rigorous review of claims adjudication. • Comprehensiveness of claims submissions (documentation) by the HCPs. • Number of type of queries raised by the ISA during review of claims – appropriateness of queries. • Accuracy of claims settlement.
CLAIMS AUDIT. (1) Express Scripts Canada may conduct a review or audit the books and records of the Provider relating to any Claims submitted by the Provider under this Agreement in order to ensure compliance with the terms and conditions of this Agreement.
(2) Any audit or review will be conducted in accordance with the following and at the times and in accordance with the other procedures set out in the Pharmacy Claims Submission Kit:
(a) Express Scripts Canada will provide the Provider with advance written notice of any audit or review and conduct the audit within the time frames set out in the Pharmacy Claims Submission Kit.
(b) The scope and coverage of any audit or review shall be determined by Express Scripts Canada and may take the form of any of the review or audit processes set out in the Pharmacy Claims Submission Kit.
(c) The Provider shall cooperate with any audit or review and shall provide such information as may be required by Express Scripts Canada, including copies of any Client profiles, prescriptions, shipping invoices, internal invoices, manufacturers' invoices, wholesalers' invoices, documentation of item receipt by the Client, and evidence of other or additional drug benefit coverage.
(d) Where access to its premises is requested by Express Scripts Canada, the Provider shall provide such access during regular business hours and shall provide reasonable assistance to Express Scripts Canada or its agents to allow them to inspect, review and take copies of any and all pharmacy records pertaining to the provision of NIHB Pharmacy Services to any Clients. Express Scripts Canada shall not, unless authorized by law or by the Provider, remove or cause to be removed any original books, records or supporting documentation from the Provider’s premises.
(3) Deleted
(4) In the event Provider fails to comply with the requirements of this Section 6, Express Scripts Canada shall have the right to reverse all applicable paid Claims (e.g., those subject to the audit) and may, pursuant to Section 10 (2), immediately terminate this Agreement, in Express Scripts Canada’s sole discretion.
CLAIMS AUDIT. HPHC shall adhere to the requirements of the Maine Uniform Accounting and Auditing Practices for Community Agencies Act, 5 M.R.S.A. § 1660-C et seq., as required by such law.
CLAIMS AUDIT. Reinsurer shall have the right to audit the claims payment practices and may prescribe claims notice dollar thresholds if it reasonably determines that Ceding Company's claims payment practices and procedures are materially inconsistent with the descriptions thereof contained in Ceding Company’s business guidelines.
CLAIMS AUDIT a. At Employer's expense, Employer shall have the right to audit Claims on Anthem's premises, during regular business hours and in accordance with Anthem's audit policy, which may be revised from time to time. A copy of the audit policy shall be made available to Employer upon request.
b. If Employer elects to utilize a third-party auditor to conduct an audit pursuant to this Agreement and Anthem's audit policy, such auditor must be mutually acceptable to Employer and Anthem. Anthem will only approve auditors that are independent and objective and will not approve auditors paid on a contingency fee or other similar basis. Anthem reserves the right to charge a fee to Employer for expenditure of time by Anthem's employees in completing any audit. An auditor or consultant must execute a confidentiality and indemnification agreement with Anthem pertaining to Anthem's Proprietary and Confidential Information prior to conducting an audit.
c. Employer may conduct an audit once each calendar year and the audit may only relate to Claims processed during the current year or immediately preceding calendar year (the "Audit Period") and neither Employer nor anyone acting on Employer's or the Plan's behalf, shall have a right to audit Claims processed prior to the Audit Period. The scope of the audit shall be agreed to in writing by the Parties prior to the commencement of the audit.
d. Employer shall provide to Anthem copies of all drafts, interim and/or final audit reports at such time as they are made available by the auditor or consultants to Employer. Any errors identified as the result of the audit shall be subject to Anthem's review and acceptance prior to initiating any recoveries of Paid Claims pursuant to Article 13 of this Agreement. Anthem reserves the right to terminate any audit being performed by or for Employer if Anthem determines that the confidentiality of its information is not properly being maintained or if Anthem determines that Employer or auditor is not following Anthem audit policy.
e. An audit performed pursuant to this Agreement shall be the final audit for the Audit Period and for any prior Audit Period unless otherwise agreed to in writing by the Parties; however, Claims may be re-audited if Employer is required to conduct the audit by a government agency with which it has a contractual arrangement.
