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

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above, the Eligible Person must reimburse Delta Dental from that recovery to the extent of payments made under the Plan. M. AssiQaunent of Benefits. Benefits to Eligible Persons are for the personal benefit of those people and cannot be transferred or assigned; provided, however, that Delta Dental may pay Participating Dentists directly on behalf of Eligible Persons. Benefits paid to Participating Dentists sha11 discharge the obligation of Delta Dental with respect to the amount of Benefits paid. N. Limitation of Services. Contractor aclmowledges and agrees that: (1) Delta Dental does not provide, direct, or control the provision of dental services to covered people (as such terms are defined by the Dental Plan); (2) the provision of contract provider infomiation in any medium by Delta Dental is not the provision of dental diagnostic or treatment services, dental advice, or health advice; (3) all decisions regarding dental services are made solely by the covered person and the practitioner rendering dental services to a covered person and the results thereof are solely within the control of the provider of such dental services providing the services and the covered person(s); and (4) Delta Dental's execution of this contract and the perfom~ance of its obligations hereunder do not constitute an undertaking by Delta Dental to render any dental services, or to assume or guarantee the results thereof to covered persons, or to guarantee that dental services will be rendered in accordance with generally accepted standards or procedures. O. Plan Fiduciary Status; Discretion. The Contractor, or a person designated by the Contractor (other than Delta Dental), shall be the "Named Fiduciary" (as defined in ERISA Section §402[a][2]) of Contractor's Dental Plan for which Delta. Dental shall provide administrative services hereunder. However, Delta Dental shall maintain authority to adjudicate claims and review all denied claims for benefits under the Dental Plan, including, but not limited to, the deternunation of covered services, interpretation of the terrns of the Dental Plan and any rules, practices, and procedures established for adjudication of claims of the Dental Plan. However, Delta Dental sha11 not have discretionary authority or control conceming the determination of eligibility for and entitlement to any benefits in accordance with the terms of the Dental Plan. Delta Dental shall not have any discretionary authority or discretionary control respecting the management of the Dental Plan itself or its assets, if any, and the Contractor retains a11 responsibility and authority, including all other fiduciary responsibility as defined in ERISA for the operation of the Dental Plan, with the exception of claims adjudication by Delta Dental as described herein. Delta Dental shall indemnify and hold harmless, the County from any and all damages, including reasonable attorney's fees, arising from or related to the negligent or improper adjudication of claims by Delta Dental. P. F~. Contractor agrees that the Contractor shall be solely responsible for funding the payment of benefits and expenses under the Contractor's Dental Plan. Q. Adjustment Procedures for Under~ayment and Overpayment of Claims. If it is determined that more or less than the correct amount has been paid under the Plan by Delta Dental, Delta Dental shall attempt, on behalf of the Contractor and the Plan, to make such adjushnents as may be necessary to have the Dental Plan pay only the amounts that are properly payable under its terms. If Delta Dental deternunes that it has, for any reason, paid a Dentist more for dental services than is provided for under the Dental Plan (the "Overpayment Amount"), Delta Dental has the right to recover the Overpayment Amount from the Dentist to which the Overpayment Amount was paid. Delta Dental will provide the Dentist with notice of the Overpayment Amount, and the basis on which Delta Dental believes that the payment made was in excess of the amount properly due under the Dental Plan, and will request that the Overpayment Amount be returned. Should the Dentist fail to return the requested Overpayment Amount, Delta Dental reserves the right to offset the Overpayment Amount from any future payments due that Dentist for dental services provided to Subscribers and/or beneficiaries under the Dental Plan, or other self-funded dental plans of sponsoring employers administered by Delta Dental; provided, however, that the amounts properly payable under any of the affected Dental Plan(s) shall be neither diminished nor enhanced by this recovery procedure. Where Overpayment Amounts are recovered by means of an offset, the Overpayment and Offset Amounts will be properly credited to, or debited from, the affected Dental Plan(s)_so that all involved Dental Plans will have been administered according to their terms and will have paid only the amount that is properly payable for the dental services provided. Revised 09/2011 9