R2006-137 AUTHORIZING AGREEMENT - Laserfiche WebLink

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The Honorable Paul Osborne ' City of Decatur August 30, 2006 Page 8 ❑ Claims were paid only for eligible individuals, based on plan provisions and documentation maintained in the claims system eligibility data. ❑ Amounts paid were within the UCR allowances and/or discounted fees for the treatment area. ❑ Benefits were paid under the proper benefit classification, diagnostic, and procedure codes. J Benefit limitations, deductibles, co-payments, coinsurance, and out-of-pocket maximums were applied. ❑ Coordination of benefits and subrogation provisions were enforced. U Arithmetic calculations were correct and duplicate claims have been properly denied. =1 Payment was timely and made to the proper party. � Deliverable for Claims Audit Segal's written report will be presented to the City four to six weeks after completion of the onsite review. Our qualitative analysis and recommendations are not necessarily based on tangibles. The auditors draw conclusions from information gathered throughout the review, relying on their experience, judgment, and acceptable industry practices or contract requirements. In addition to documenting the audit process and summarizing our findings, our report will include any recommendations for improving the overall claims administration process. Our goal is to develop recommendations to address problems uncovered in the audit that will be beneficial to the efficiency and/or financial position of the Plan. As applicable to the scope of audit services, our report will include: J Comparison of actual procedures and performance to industry standards; J Total number of claims examined and total dollar amount represented in the claims audited; J Total dollar amount of financial errors (overpayments and underpayments combined); J Number of claims audited versus number of claims with errors, separately and combined for financial and procedural errors; and J Processing time (business/calendar days) from receipt in the claims office to date of processing. Timetable The onsite review will be conducted at Consociate Dansig's Decatur, Illinois claims office at a time mutually agreed upon by all parties. Prior preparation (data request, receipt of data, claims selection, retrieval of claim documentation, etc.) for this onsite visit is estimated at four to five weeks; however, delays may be experienced (i.e., executed audit agreement, onsite accessibility,