R2007-236 AUTHORIZING AGREEMENT WITH BLUE CROSS BLUE SHIELD OF ILLINOIS

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�' � y M 4�l_ �. the policies and procedures governing software used lo process C.laims for services rendered by the Claim Administrator's Providcrs, Ilost Plans' Yrovidcrs and thc S�rvicing Plans' Yrovidcrs may resul� in minor dcviations in C1aim processing and/or pricing of Claims for same services. SLCTION 16: MLDICARL SGCONUARY 1'AYI:IZ ("MSY") llA"1'A MA'i'CII lfi.l In �n e1l�ort to facilitate the processing of Claims consislent with the requirements of'the MSP slalute, and lo assist in meeting the statutory obligations, certain Blue Cross and Blue Shield Plans together with the Centers 1�or Medicare & Medicaid Services("CMS"), formerly known as I-lealth Care Financing Administration ("I-ICFA"), the federai govern- ment agency which administers Medicare, have developed a new enrollment and membership system.The system,also referred to as the "Data Match," is aimed at obtaining, in a Timely and current fashion, information necessary for the Ciaim Administrator to identify dual coverage situations which fall within the MSP statute, and to determine whether primary or secondary payment should be made for a particular Claim. 16.2 Under the system,the Claim Administrator will provide basic information to CMS about individuals enrolled in Group Health I'lans who are also covered by Medicare so that CMS can better detect dual coverage situations. 16.3 "1'he Employer hereby authorizes and directs the Claim Administrator to disclose to CMS periodically, information per- faining to Medicare-eligible Covered Persons under the Plan. 16.4 The Employer agrees th�t the Claim Administrator's ability to mahe accurate primary/secondary MSP determinations depends on the breadth and accuracy of the Claim Administrator's files concerning Covered Persons. The Employer agrees to use best efforts in responding promptly and accurately to the Claim Administrator's requests for information and to require and facilitate its Covered 1'ersons' cooperation in responding promptly and accurately to such requests. 1(.5 l'urther, to assure the continuing accuracy of the Claim Administrator's files,the Employer agrees that it is the Employer's responsibility to notify the Claim Administrator promptly of'any change in the size of the Employer's work i�orce or status of its employees that might affect the order of payment under the MSP statute,such as infonnation regarding working- aged persons who retire and changes in the size of the Employer's worh force that place it in,or take it out of,the scope of the MSP statute. If the Claim Administrator does not receive such information from the Employer,the Claim Adminis- trator will assume that all relevant facrors remain unchanged and will process Claims accordingly.The group acknowl- edges and agrees that the Claim Administrator will be using the information provided by the Employer and Covered Per- ' sons to update the Claim Administrator's files, and will also forward this information to CMS so that CMS can revise its file to reflect relevant changes in primary/secondary status. 16.6 The Claim Administrator may, in its sole discretion,discontinue its participation in the Data Match system as described , above. Nothing in the Agreement shall be construed as obligating the Claim Administrator to continue its participation in the Data Match system. i lfi.7 Disclosure Statement:The Employer acknowledges that the Claim Administrator has furnished it with a copy of a pam- phlet entitled"Ini�ormation Regarding the Medicare Secondary Payer Statute"(also referred to as the"Disclosure State- I menY'), prepared by the Blue Cross and Blue Shield Association and reviewed by CMS, which administers Medicare. I S�C1'ION 17: I2LIMI3URS�M�NT PROVISION ' 17.1 If a Covered Person incurs expenses for sickness or injury that occurred due to Ihe negligence o1'a third party and benefits II are provided for Covered Services described in the Plan, the following provisions will apply: II a. The Claim Administrator on behalf'of the Employer has the right to reimbursement for all benefits the Claim Admin- istralor provided from any and all damages collected lrom the third party ibr those same expenses whether by action at law, settlemenl, or compromise, by the Covered I'erson, [he Covered Person's parents, if the Covered Person is a minor,or the Covered Nerson's legal representativc as a result of that sickness or injury, in the amount of the total Gligible Charge or Provider's Claim Charge 1�or Covered Services for which the Claim Administrator has provided benefits to the Covered Person, reduced by any Average Discounl Percentage ("ADI'") applicable ro the Covered Person's Claim or Claims. IiCSC'Il.nSA Rev.6/p7 -��-