Co-Payment Match Substantiation Method Sample Clauses

Co-Payment Match Substantiation Method. To the extent permitted by IRS guidance, charges shall be considered substantiated if they satisfy the “co-payment match substantiated method” as set forth in Rev. Rul. 2003-43, Notice 2006-69, Notice 2007-2 and superseding or additional IRS guidance. Under that method, a charge is considered substantiated without the need for submission of a receipt or further review if the Adopting Employer’s group health plan has co-payments in specific dollar amounts, and the dollar amount of the transaction at a health care provider (as identified by its merchant category code), or other merchant/service provider as otherwise allowed by IRS guidance, equals an exact multiple of not more than five times the dollar amount of the co-payment for the specific service (i.e., pharmacy benefit co-payment, co-payment for a physician’s office visit, etc.) under the Adopting Employer’s group health plan covering the specific Participant. In addition, if a health plan has multiple co-payments for the same benefit (e.g., tiered co-payments for a pharmacy benefit), exact matches of multiples or combinations of the co-payments (but not more than the exact multiple of five times the maximum co-payment) will similarly be fully substantiated without the need for submission of a receipt or further review.