Procedure for Benefits Modifications 1. Proposals for major retirement benefit modifications will be negotiated in joint meetings with the certified employee organizations whose memberships will be directly affected. Agreements reached between Management and organizations whereby a majority of the members in LACERS are affected shall be recommended to the City Council by the CAO as affecting the membership of all employees in LACERS. Such modifications need not be included in the MOU in order to be considered appropriately negotiated.
Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed through Inter-Plan Arrangements, as described above, except for all dental benefits, and those prescription drug benefits or vision benefits that may be administered by a third party contracted by us to provide the specific service or services. BlueCard® Program Under the BlueCard® Program, when you receive covered healthcare services within the geographic area served by a Host Blue, BCBSRI will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating providers. When you receive covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for covered healthcare services is calculated based on the lower of: • the billed covered charges for your covered services; or • the negotiated price that the Host Blue makes available to BCBSRI. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.
Reconsiderations and Appeals If you experience a problem relating to an authorization review, benefit denial, or other aspect of this plan, we have internal and external procedures to help you resolve your issue. The following sections detail the processes and procedures for filing: • Administrative Appeals; • Medical Reconsiderations and Appeals (including expedited appeals); • Prescription Drug Appeals: and
MEMBERS OF DIPLOMATIC MISSIONS AND CONSULAR POSTS Nothing in this Agreement shall affect the fiscal privileges of members of diplomatic missions or consular posts under the general rules of international law or under the provisions of special agreements.
Dismissal for Cause The following procedures shall apply in all cases of dismissal for cause:
Alternative Arbitration Proceedings Alternatively, the Parties may refer the matter to the Nairobi Centre for International Arbitration (NCIA) which offers a neutral venue for the conduct of national and international arbitration with commitment to providing institutional support to the arbitral process.
Resolution of Employee Dismissal or Suspension Disputes The following procedure shall be used for the resolution of disputes relating to the dismissal or suspension of an employee(s):
Re-employment After Voluntary Termination or Dismissal for Cause Where an employee voluntarily leaves the Employer's service, or is dismissed for cause and is later re-engaged, seniority and all perquisites shall date only from the time of re-employment, according to regulations applying to new employees.
Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:
GRIEVANCE PROCEDURE AND ARBITRATION 8.01 For purposes of this Agreement, a grievance is defined as a difference arising between the parties relating to the interpretation, application, administration or alleged violation of the Agreement including any question as to whether a matter is arbitrable.
