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r <br /> .� <br /> ti , <br /> �XHII3IT 1 <br /> CLAIM ADMINIS 1'RA'I'OR SLRVIC�S <br /> • CLAIMS AD,JUllICA7'ION <br /> Lxamination of Claims and determination oi' payment levels, including data entry of Claims by Claims departments, <br /> mainlenance of Claims experience files, use of inedical consultants, review of utilization and reasonable and customary <br /> charges and Coordination o1�Benefits (COB). <br /> • I;XPLANATION Or B�N�P'I`I'S (rOI3) <br /> Preparation of EOBs. <br /> • CLAIMS/M�MI3rRSHIP INQUIRI�S <br /> ' Handling of inquiries -- written, phone or in-person - related to membership, beneP�its, and Claim Payment, Net Claim <br /> Paymenl or denial. <br /> • LNROLLM�NT S�RVIC� <br /> Upon Employer request,assist Employer, in accordance with Claim Administrator's standard procedures, in initial enroll- <br /> ment activi[ies, inciuding education oi�Covered Persons about benefits, the enrollment process, selection o{'health care <br /> providers and how to file a Claim for henefits; issue Claim submission instructions on behalf of Employer to,�.health care <br /> providers who render services to Covered Persons. <br /> • CLII;N'1'SGIiVIC�S AND MA1'�IZIALS <br /> Provision of those items as elected by Employer from listing below: <br /> a. Enrollnzent Maleriuls. Implementation materials to be provided by Claim Administrator's Marketing Administra- <br /> tion Division during the enrollment process;any custom designed materials may be subject to Supplemental Charge. <br /> b. Standar�!Identification Cards. Provision o1�identification cards appropriate to health benefit Plan coverage(s)se- <br /> lected. <br /> c. Sta►adnrd Proi�ider Directories. Access lo Network Provider direcrories and periodic updates to such, if applicable <br /> to the health benefit Ylan coverage(s) under the Agreement. <br /> d. Custonzer Sernice. Access to toll-free customer service telephone number. <br /> e. Medical Pre-notificatiort Helpline. For those services determined by Employer and provided in writing to Claim <br /> Administralor that require pre-notification, advance Claim Administrator review of inedical necessity of such ser- <br /> vices covered under the Plan; access to toll-fi�ee medical pre-notification helpline for Covered Persons and their <br /> health care providers to call for assistance. <br /> • M�MI3�RSHII' VALIDATION � <br /> Verification of inembership by wire, listing, electronic on-line query or other method prior to or during adjudication. <br /> • MGMB�RSHIP TILr UPllA1'�S <br /> Maintenance of inembership status files, processing of inter-plan iransfers and processing of contract changes. <br /> • O"1'IIER MrM13I:RSIIIY SI:RVICCS <br /> Contact �mployer and/or Covered Gmployees regarding adding, changing or renewing coverage. <br /> • S'IANllARD Ii�POR7'S <br /> Make available Claim data,Claim Settlement statements(as outlined in Exhibit 2,Section f)and periodic reports in Claim <br /> Administrator's standard format(s) in accordance with Claim Administrator's standard reporting policy. <br /> IiCS('II./�SA Rev.G/07 -17- <br />� <br />