Medical Prior-Authorization Service Telephone Number Sample Clauses

Medical Prior-Authorization Service Telephone Number. For those services determined by Employer and provided in writing to Claim Administrator that require prior authorization, advance Claim Administrator review of medical necessity, based on Claim Administrator’s standard medical and utilization management criteria and policies, of such services covered under the Plan; access to toll–free medical prior-authorization service telephone number for Covered Persons and their health care Providers to call for assistance. • INTERNAL APPEALS Determination of properly filed internal appeal requests received by Claim Administrator from a Covered Person or a Covered Person’s authorized representative. • MEMBERSHIP Using membership information provided to Claim Administrator by Employer to make Claim and appeal determinations and for other purposes as described in the Agreement. • STANDARD REPORTS Make available Claim data, Claim settlements (as outlined in Exhibit 2, Section 6) and periodic reports in Claim Administrator’s standard format(s) in accordance with Claim Administrator’s standard reporting processes at no additional charge. Any additional reports required by Employer must be mutually agreed upon by the Parties in writing prior to their development and may be subject to a Supplemental Charge. • STOP LOSS COORDINATION Coordinate all necessary reporting, tracking, notification and other similar financial and/or administrative services pursuant to settlements under stop loss policy(ies) purchased (or proposed to be purchased) from Claim Administrator in conjunction with the Agreement. For stop loss coverage purchased from entity(ies) other than Claim Administrator, such coordination is limited to this Exhibit’s STANDARD REPORTS to be made available to Employer subject to the Agreement’s disclosure requirements. • REPORTING SERVICES Preparation and filing of annual Internal Revenue Service (“IRS”) 1099 forms for the reporting of payments to health care Providers who render services to Covered Persons and who are reimbursed under the Plan for those services. • ACTUARIAL AND UNDERWRITING Provide Claims projections and pricing of administrative services and stop–loss coverage. • FRAUD DETECTION AND PREVENTION Identify and investigate suspected fraudulent activity by Providers and/or Covered Persons and inform Employer of findings and proof of fraud applying Claim Administrator’s standard processes; address any related recovery litigation as set forth in Exhibit 6. • EMPLOYER PORTAL (currently called “BLUE ACCESS FOR...