Eligibility Administration Sample Clauses
The Eligibility Administration clause defines the procedures and responsibilities for determining and managing who qualifies for certain benefits, services, or participation under an agreement. Typically, this clause outlines the criteria for eligibility, the documentation required, and the process for reviewing and updating eligibility status. For example, it may specify how and when participants must provide proof of eligibility or how changes in status are reported and processed. Its core function is to ensure that only qualified individuals or entities receive the intended benefits, thereby maintaining compliance and reducing the risk of errors or misuse.
Eligibility Administration. The Benefits Center on behalf of the County will determine participant eligibility and provide Contractor with eligibility records. Contractor will be entitled to rely on the eligibility information the County provides and will not maintain or independently verify any portion of the Plan eligibility records. The Benefits Center, on behalf of the County, will provide Contractor with changes in enrollment as soon as practical in the month in which a change in eligibility occurs, but generally no later than sixty (60) calendar days after the effective date of change. Changes in eligibility will be effective on the first of the month, whenever possible. Eligibility information will include new Plan Participants and effective dates of coverage, changes in types or levels of coverage for existing Plan Participants and effective dates of termination of coverage. As Plan Administrator, the County will be responsible for billing and compliance with other administrative requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99-272 ("COBRA"), as amended, and will include qualified beneficiaries eligible to participate under the Plan pursuant to COBRA in the eligibility information provided to Contractor. Contractor shall:
1. Accept and load eligibility information weekly, within 48 hours of receipt from the Benefits Center. Contractor shall accept eligibility electronically in the County’s current ANSI 834 formatted file and future formats as required by Federal laws and regulations. Provide industry standard file discrepancy reports within 48 hours of receipt of the weekly eligibility file and work with the Benefit Center to research and resolve file discrepancies in a timely manner.
2. Contractor shall notify County or its designee, if the eligibility file is not received by the due date identified on the file schedule provided by the County’ Benefit Center.
3. Contractor shall notify County or its designee prior to the eligibility update application, of any material errors or coding problems on the eligibility file that exceeds agreed upon thresholds.
4. Provide urgent verification of coverage and/or eligibility updates within one (1) business day as directed by the Benefits Center when needed to provide access to care in between eligibility file transmissions.
5. Reconcile enrollment and administrative fee of Plan Participants with the Benefits Center records monthly. Correct information to match the County enrollment information and mai...
Eligibility Administration. Contractor accepts employee eligibility/payroll information and any active leave data in most electronic formats, including Excel. Downloading of data into Contractor’s system prior to implementation of services will facilitate accurate and timely service delivery to MPS and its employees. Contractor will provide a tail (take-over) claim file layout to MPS to be used to provide the data associated with any/all existing and historical leaves and/or absence activity. Likewise, the Contractor will provide take-over claim file layout to MPS to be used to provide the data associated with any/all existing ADAAA/WFEA accommodation requests. MPS’s implementation is a detailed process that is led by an experienced Implementation Manager in an approach Contractor recommends is completed with weekly scheduled calls from “Kickoff” until the “Go Live” date and thereafter as needed. This resource is both a project manager and a subject matter expert. Following a detailed, structured project plan, Contractor will discuss every detail with MPS to ensure a complete understanding of how MPS desires the program be customized, including best practices that keep MPS current and compliant. It is the intent of the parties to develop a timeline for implementation which will include a benchmark for “Go Live”. Contractor shall provide fair and consistent administration of Family Medical Leave in compliance with federal and state requirements. Accurate time tracking and reporting of absences is provided. For FMLA, leave can be tracked in Contractor’s system based on any 12-month period and in any increments of time compatible with MPS payroll system. MPS currently utilizes a “rolling” 12-month period for federal FMLA claims and a calendar year for Wisconsin FMLA claims. Upon intake, Contractor’s MPS-designated Absence Management Specialist, in consultation with the designated Nurse Care Manager, Medical Director or other staff MDs, on an as-needed basis, will determine initial eligibility under the FMLA as well as any state-mandated leave requirements. On behalf of MPS, Contractor will notify the employee, within two (2) business days of the initial leave notification, of his/her eligibility for FMLA leave. Included in the initial written notification is information regarding the employee’s rights/responsibilities and MPS leave policies as well as the required attending physician form/certification form (and other forms as applicable) to be completed within 15 days of the initial le...
Eligibility Administration. The County will determine participant eligibility and provide Contractor with eligibility records. Contractor will be entitled to rely on the eligibility information the County provides and will not maintain or independently verify any portion of the Plan eligibility records. The County will provide Contractor with changes in enrollment as soon as practical in the month in which a change in eligibility occurs, but no later than sixty (60) calendar days after the effective date of change. Changes in eligibility will be effective on the first of the month, whenever possible. Eligibility information will include new Plan Participants and effective dates of coverage, changes in types or levels of coverage for existing Plan Participants and effective dates of termination of coverage. As Plan Administrator, the County will be responsible for billing and compliance with other administrative requirements of the Consolidated Omnibus Budget Reconciliation Act of 1985, P.L. 99- 272 ("COBRA"), as amended, and will include qualified beneficiaries eligible to participate under the Plan pursuant to COBRA in the eligibility information provided to Contractor. Contractor shall: