R99-183 AUTHORIZING APPLICATIONS

Home Browse Search

Attention: Mr. Richard Rappenecker � If to the Employer: City of Decatur #1 Civic Center Plaza Decatur, IL 62523 Attention: Mr. J. Barry Leonard XXVI. DEFINITIONS A. "Average Discount Percentage ("ADP")" means a percentage discount determined by the Claim Administrator that will be applied to a Provider's Eligible Charge for Covered Services rendered to Covered Persons by Hospitals and certain other health care facilities for purposes of calculating Coinsurance amounts, deductibles, out-of-pocket maximums and/or any benefit maximums. The ADP will often vary from Claim to Claim. The ADP applicable to a particular Claim for Covered Services is the ADP, current on the date the Covered Service is rendered, that is determined by the Claim Administrator to be relevant to the particular Claim. The ADP reflects the Claim Administrator's reasonable estimate of average payments, discounts and/or other allowances that will result from its contracts with Hospitals and other facilities under cir- cumstances similar to those involved in the particular Claim, reduced by an amount, not to ex- ceed 15%of such estimate,to reflect related costs. (See provisions ofthis Agreement regarding "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PROVID- ERS.") In determining the ADP applicable to a particular Claim,the Claim Administrator will take into account differences among Hospitals and other facilities, the Claim Administrator's con- tracts with Hospitals and other facilities,the nature of the Covered Services involved and other � relevant factors.The ADP shall not apply to Eligible Charges when the Covered Person's bene- fits under the Plan are secondary to Medicare and/or coverage under any other group program. B. "Certificate of Creditable Coverage" means a certificate disclosing information relating to an I individual's Creditable Coverage under a health care benefit program for purposes of reducing any preexisting condition exclusion imposed by any group health plan coverage. Under this i Agreement, Certificate of Creditable Coverage means a certificate, issued by the Claim II Administrator, at the written direction of the Employer, to an individual whose coverage under this Agreement has terminated and which discloses information relating to Creditable Cover- ', age under the Agreement for the purposes of reducing any preexisting condition exclusion that ', may be imposed by coverage under any subsequent group health plan. I C. "Claim" means notification in a form acceptable to the Claim Administrator that service has � been rendered or furnished to a Covered Person. This notification must set forth in full the de- I, tails of such service including, but not limited to,the Covered Person's name,age,sex and iden- '' tification number, the name and address of the Provider, a specific itemized statement of the , service rendered or furnished,the date of service, applicable diagnosis and the Claim Charge ', ' for such service. D. "Claim Charge"means the amount which appears on a Claim as the Provider's regular charge for service rendered to a patient,without further adjustment or reduction and irrespective of any i se arate financial arran ement between the Claim Administrator and the articular Provider. P 9 P « , See rovisions ofthis A reement re ardin CLAIM ADMINISTRATOR S SEPARATE FINAN- ( P 9 9 9 CIAL ARRANGEMENTS WITH PROVIDERS.") E. "Claim Payment"means the benefit provided by the Claim Administrator, plus any related Sur- charges, upon submission of a Claim, in accordance with the benefits specified in the Plan.All � Claim Payments shall be calculated on the basis of the Provider's Eligible Charge for Covered Services rendered to the Covered Person, irrespective of any separate financial arrangement - 16 -