2012-038 Human Resources - Delta Dental Claims & Administrative fees

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To make payments for Covered Services provided to Eligible Persons based on the lesser of the Submitted Amount or the PPO Dentist Schedule. Delta Dental will send payment directly to Participating Dentists and the Eligible Person will be responsible for any applicable Copayments or Deductibles. If the Dentist is not a PPO Dentist, but is a Premier Dentist, the Eligible Person wi11 also be responsible for any difference between the PPO Dentist Schedule and the Premier Dentist Schedule for Covered Services, in addition to Copayments or Deductibles. Unless prohibited by state law, the Eligible Person will be responsible for the Maximum Approved Fee for most commonly-performed non-covered services. For other non-covered services, the Eligible Person will be responsible for the Dentist's Submitted Amount. For Covered Services rendered by a Nonparticipating Dentist or Out-of-Country Dentist, Delta Dental will usually send payxnent to the Subscriber, who is responsible for making full payment to the Dentist. The Eligible Person will be responsible for any difference between Delta Dental's payment and the Dentist's Submitted Amount. 6. Consistent with any applicable law protecting the confidentiality of a patient's health records, data, or information, to make standard reports available to Contractor at no additional charge and to provide non-standard reports for an additional charge based on the time and materials necessary to create the reports. 7. To allow the Contractor the right to audit its files, books, and records (both paper and electronic) pertaining to services provided. The Contractor will beaz the entire cost of any such audits. The Contractor may assign this right to audit to an agent, provided the agent is a licensed firm and the audit is led by an individual who holds a nationally recognized audit accreditation. Delta Dental will allow the Contractor or the Contractor's agent to audit the work areas at which services under this Contract aze performed, within 14 business days of receipt of a fully-signed Authorization, Hold Hannless and Indemnification Agreement consistent with the limitations imposed by applicable law. Where applicable, Delta Dental agrees to segregate the Contractor's records from third-party records in order to allow accurate assessment of Contractor-specific processes. Such audits will take place no more than once in a 12-month period, unless both the Contractor and Delta Dental mutually agree that there is reasonable cause to conduct an audit more frequently, in which case the Contractor will give 14 business days' written notice before such audit. During the audit, if claims samples are selected using a financially stratified methodology, the results will be extrapolated to the entire population of claixns during the audit period using a weighted average method for each category. B. Contractor Agrees: 1. To pay Delta Dental the Administrative Services Fees and Claims Payment Reimbursement amounts specified in Exhibit A as billed by Delta Dental, with no payment adjustments for updates not yet reflected on the current invoice. If payment is not received by the due date, Delta Dental shall, notify Contractor and shall have the right to suspend claims processing if payment is not received within two (2) business days from notification, have the right to suspend claims processing. Delta Dental may, at its sole option, send notification to the Contractor of an adjustment in Rates, Benefits, or Copayments to correct potential adverse group experience resulting from the following: a. Information provided upon enrollment proves to be in error; or b. Terms and provisions of the Plan are violated; or c. Invoices are not paid as billed. Delta Dental will provide the Contractor written notice 60 days prior to implementing any adjustment. If the Contractor refuses to accept this adjustment, Delta Dental may, in its sole discretion, implement the adjustment, implement an alternative adjustment acceptable to both parties, or cancel this Plan. Revised 09/201 I 6