Claims Processing Services. (a) PBM shall process Claims in real time consistent with applicable law, including ERISA and any other applicable state or federal law.
(b) PBM shall provide to WellPoint daily accumulator files for each of WellPoint’s systems and in accordance with WellPoint’s specifications for each system.
(c) With respect to Plans subject to ERISA, PBM will comply with the applicable Plan terms, ERISA and the regulations thereunder regarding Claims appeals. PBM will forward all appeals and related information received to WellPoint within [*] of receipt. PBM shall arrange prompt payment of benefits if the initial denial is not affirmed by WellPoint. PBM shall have no responsibility for Plan, provider or Covered Individual grievances and appeals.
(d) PBM shall enter into its electronic on-line Claims adjudication system certain Plan design information necessary for PBM to perform automated Claims processing services in accordance with this Agreement, including information regarding Cost Share, Covered Individual out-of-pocket maximums, benefit maximums and any other features of the Plan design to be used in processing Claims. PBM will instruct Network Pharmacies to transmit certain information to PBM when a Covered Individual presents a Plan identification card. PBM will transmit to Network Pharmacies the Claim status; the Cost Share amount (if applicable); and any applicable drug utilization review messaging or other messages that are part of the Claims adjudication process.
(e) PBM shall process Claims under this Agreement in accordance with the terms hereof.
(f) PBM will perform electronic, telephone, and on-site audits of Network Pharmacies to determine compliance with their pharmacy agreements. PBM will attempt recovery of identified overpayments to Network Pharmacies through offset, demand or other reasonable means; provided that PBM will not be required to institute litigation. Recovered overpayments shall be credited to WellPoint.
(g) If PBM determines that, through its error (e.g., PBM processed eligibility incorrectly or incorrectly set up benefit design), it has paid any Covered Individual on a manually submitted Claim less than the Covered Individual is entitled to under the Coverage Document, PBM shall adjust the underpayment consistent with its standard policies. If PBM determines that, through its error, it has overpaid any Network Pharmacy or paid benefits not covered under the terms of a Coverage Document, PBM shall, at its own expense, recover the over...
Claims Processing Services. TT agrees to edit and process detailed demographic, insurance, and provider information to process all claims. TT will submit all claims within three (3) business days of receipt of completed claim information, allowing time to process cancellations.
Claims Processing Services. ProAct shall provide Claims processing services related to Claims for prescriptions dispensed on or after the Effective Date of this Agreement. ProAct shall process Claims received from Participating Pharmacies and Plan Participants, determine whether such Claims qualify for reimbursement in accordance with the terms of the applicable Benefit Plan and determine the applicable payment. ProAct agrees to process Claims within National Council for Prescription Drug Programs (NCPDP) prevailing standards. ProAct shall process Claims within the time frames established by applicable state and federal law. Upon termination of this Agreement, ProAct shall be obligated to process only those Claims which are for prescriptions dispensed before the termination date and which are received by ProAct within ninety (90) days of the termination date. Any Claims submitted and processed after the termination date will be invoiced at the rates set forth for such Claims in Exhibit A. ProAct shall arrange for the following services to be provided upon receipt of a Claim:
(a) Verify that the patient for which the prescription has been claimed is a Plan Participant and is entitled to Prescription Drug Services.
(b) If applicable, verify that the prescriber is an authorized prescriber under the Benefit Plan.
(c) Verify that the medication dispensed is a drug covered by the Benefit Plan.
Claims Processing Services. Any intimation of claim and receipt of claim papers by the respective Underwriting Office of the Insurer shall be forwarded to the Regional Processing Office of the TPA on the same day. The claims processing service provided by the TPA along with the responsibilities of the TPA as detailed in the clauses 10, 11 and 12 read with Schedules I to IV is collectively referred to as the "CPP Service".
Claims Processing Services. PBM shall provide the following Claims processing services related to prescriptions dispensed on or after the Effective Date.
Claims Processing Services mean eligibility determination and verification efforts prior to processing claims for prescriptions dispensed for Eligible Members in accordance with the terms of the Plan Design Document within the standards adopted under the Health Insurance Portability and Accountability Act of 1996 Regulations for Electronic Transactions.
Claims Processing Services. The Claims Processor is empowered and required to act with respect to the Program only as expressly stated in the CPA Agreement and in this Agreement. The Claims Processor's role shall be limited to that of claims processor under the Program, and the services rendered by the Claims Processor under this Agreement and the CPA Agreement shall not include the power to exercise control over the Employer’s Plan assets, if any, or otherwise, be deemed to be the "Plan Administrator" or a "Fiduciary" with respect to the Program. The Claims Processor is not a “Covered Entity” under the Health Insurance Portability and Accountability Act of 1996 as amended and has an executed Business Associate Agreement with APBA.
Claims Processing Services. ~ - ;• FAA shall' (a) determine the amount of Vision .Benefits payable, if any, for each claim; (b) n~ tify the Member itS decision • concerning the claim; {c) disburse payments fo the Participating Provider (per the Participating Provider Agreeme fit) or the .Member (per the out-of-network information on Exhibit B), as applicable.- FAA's services under this paragraph shall comply - -with the provisions of ERISA Section 503 and its implementing regulations, to the extent that they address initial claims for • . benefits.. ~ - . F j ~ . ( fi 4. .
Claims Processing Services. MiliRisk shall provide claims processing services for and on behalf of Millers Mutual and Millers Casualty which shall include, but shall not be limited to:
(a) investigating, evaluating, appraising, settling and/or giving notice of the necessity to defend all claims;
(b) reporting claims settlements to Millers Mutual and Millers Casualty which, if any payment is required, Millers Mutual or Millers Casualty, as appropriate, shall pay directly;
(c) apprising Millers Mutual and Millers Casualty of major developments which arise in the administration, investigation, adjustment, or settlement of a particular claim and to communicate with Millers Mutual or Millxx'x Xxxualty's designated representative regarding all important matters concerning the proper disposition of claims involving complex or questionable circumstances. "Major developments" within the context of this section are understood to mean:
(i) controverted claims;
(ii) receipt of an adverse medical report, e.g., "injury more serious than originally reported;"
(iii) death of claimant;
(iv) adverse ruling from a court; or
(v) the need for attorney representation in a previously unrepresented case; (d) refraining from disclosing the contents of Millers Mutual or Millers Casualty's files to third parties except as is reasonably necessary in carrying out the responsibilities under this Agreement or in delegating certain responsibilities to others as legally required;
(e) maintaining a complete and accurate file on each reported claim.
Claims Processing Services. The Provider agrees to provide to TT detailed information on all current patients being seen by the Provider who have an outstanding balance with TT. The Provider further understands that such detailed information is required in order for TT to carry out its responsibilities under this Contract. The Provider understands that obtaining this information is the Providers responsibility. This information must be posted, in full, to TT’s Application.
