PLAN DOCUMENTS. The documents that set forth the terms of the Plan, and which include the Summary Plan
Description and the Benefits Booklet.
PRESCRIPTION DRUG. Insulin and those drugs and drug compounds that are included in the U.S. Pharmacopoeia
and that are required to be dispensed pursuant to a prescription or that are otherwise included on Anthem's formulary
(e.g., certain over-the-counter drugs).
PROPRIETARY INFORMATION AND CONFIDENTIAL INFORMATION. Employer's Proprietary Information is
information about the systems, procedures, methodologies and practices used by Employer to run its operations and
the Plan and other non-public information about Employer. Anthem’s Proprietary Information is non-public, trade
secret, commercially valuable, or competitively sensitive information, or other material and information relating to the
products, business, or activities of Anthem or an Anthem Affiliate, including but not limited to: (1) Information about
Anthem's Provider networks, Provider negotiated fees, Provider discounts, and Provider contract terms; (2)
information about the systems, procedures, methodologies, and practices used by Anthem and Anthem Affiliates in
performing their services such as underwriting, Claims processing, Claims payment, and health care management
activities; and (3) combinations of data elements that could enable information of this kind to be derived or calculated.
Anthem's Confidential Information is information that Anthem or an Anthem Affiliate is obligated by law or contract to
protect, including but not limited to: (1) Social Security numbers; (2) Provider tax identification numbers (TINS); (3)
National Provider Identification Numbers (NPls); (4) Provider names, Provider addresses, and other identifying
information about Providers; and (5) drug enforcement administration (DEA) numbers, pharmacy numbers, and other
indentifying information about pharmacies.
PROVIDER. A duly licensed physician, health professional, hospital, pharmacy or other individual, organization
and/or facility that provides health services or supplies within the scope of an applicable license and/or certification
and meets any other requirements set forth in the Benefits Booklet.
SUBSCRIBER. An employee or retiree of Employer or other eligible person (other than a dependent) who is enrolled
in the Plan.
SUMMARY PLAN DESCRIPTION ("SPD"). A document provided to Subscribers by Employer or its designee that
describes the health care benefits available to Members under the Plan, their rights under the Plan and the
obligations of the Plan. This document may incorporate the Benefits Booklet. In the event of any conflict or
inconsistency between the Summary Plan Description and the Benefits Booklet, the terms of the Benefits Booklet
shall control Anthem's performance under this Agreement.
VENDOR. A person or entity other than a Provider, including an Anthem Affiliate, that provides services or supplies
pursuant to a contract with Anthem.
ARTICLE 2 - ADMINISTRATIVE SERVICES PROVIDED BY ANTHEM
a. Anthem shall process the enrollment of eligible individuals and termination of Members as directed by the
Employer subject to the provisions of this Agreement. Anthem shall, with the assistance of Employer,
respond to direct routine inquiries made to it by employees and other persons concerning eligibility in the
Plan.
b. Anthem shall perform the following Claims administrative services:
1. Process Claims with a Claims Incurred Date indicated in Section 1 of Schedule A and provide
customer service at a level consistent with industry standards, including investigating and
reviewing such Claims to determine what amount, if any, is due and payable according to the
terms and conditions of the Benefits Booklet and this Agreement. Anthem shall perform
coordination of benefits ("COB") with other payors, including Medicare. In processing Claims,
Anthem shall utilize Anthem's medical policies and medical policy exception process, its definition
of medical necessity, its precertification and/or preauthorization policies and applicable Claim
timely filing limits.
2. Disburse to the applicable individuals or entities (including Providers and Vendors) payments that
it determines to be due according to the provisions of the Benefits Booklet.
Enterprise Administrative Services Agreement — October 2012 Master Template 3
City of Nashua 06/17/2013
