R96-148 AUTHORIZING APPLICATIONS

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� B. The Claim Administrator is not the plan administrator of the Employer's separate ERISA welfare benefit plan. Rather, the "Plan Administrator" means the administrator of the separate ERISA welfare benefit plan established by the Employer which is partially or fully implemented through this Agreement. "Named Fiduciary" means those persons appointed as such by the Employer under the separate ERISA welfare benefit plan established by it with certain fiduciary responsibi- lities with respect to the Employer's ERISA welfare benefit plan. The Claim Administrator is not a named fiduciary with respect to the Employer's separate ERISA welfare benefit plan."Sponsor" means the Employer, as the plan sponsor of its ERISA welfare benefit plan. C. Section 402(c)(2) of ERISA provides that an employee welfare benefit plan may provide that a named fiduciary or a fiduciary designated by a named fiduciary pursuant to a plan procedure (in- cluding a plan administrator) may employ one or more persons to render advice with regard to any responsibilities such fiduciary has under the ERISA welfare benefit plan.The Claim Adminis- trator's responsibilities hereunder are intended to be limited to those of a contract claims adminis- trator rendering advice to and administering claims on behalf of the plan administrator of the Em- ployer's plan. As such, the Claim Administrator is intended to be a service provider but not a fiduciary with respect to the Employer's ERISA welfare benefit plan. The Employer represents that its ERISA welfare benefit plan contains the plan procedure described above regarding the designation of responsibilities under a plan, and accordingly, the Claim Administrator may, pur- suant to Sections 402(c)(2) and 405(c)(1)(B) of ERISA, render advice with respect to claims and administer claims on behalf of the plan administrator of the Employer's ERISA benefit plan. The Claim Administrator has no other authority or responsibility with respect to Employer's employee benefit plan. XVIII.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 of this 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. "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- 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. • C. "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 separate financial arrangement between the Claim Administrator and the particular Provider. - 12 -