(a)
(b)
(c)
(d)
(e)
Drafting or specifying all documents, forms and records to be used
by Contracting Providers for their claims of reimbursement and to be
used by HPHC to reimburse them and also to develop procedures
to be utilized in the adjudication of claims;
Evaluating and processing all claims for payment submitted to
HPHC under the Plan. HPHC shail investigate reported health care
claims in the manner and to the extent necessary and supervise a
settlement of those health care claims and other demands that the
Plan is legally obligated to pay; prepare checks or drafts drawn
again the Purchaser’s funds allocated to the Plan to settle such
claims or demands; and maintain claim files for the Plan; and
Utilization and Peer Review. HPHC shall maintain systems, trained
staff and procedures necessary or appropriate for the operation of a
reasonable and appropriate utilization review and quality assurance
program that meets generally accepted standard and which reviews
services required under the Plan. Utilization/Case Management
Services included but are not limited to: prior authorization,
precertification, concurrent and retrospective utilization review,
discharge planning, physician review of denials and appeals,
specialty case management, and disease management programs.
In all cases, using its best efforts to advise Purchaser of any
disputed health care claims by Members over which litigation has
been commenced or threatened or which is reasonably iikely to
result in litigation, HPHC will follow its standard practices for
resolving such claims. HPHC shall also refer to Purchaser any
other health care claims where the facts available to HPHC do not
provide adequate basis for resolution of the claim by HPHC and
determination of the claim may involve the exercise of discretion. In
all such disputed or unresolved cases, the ultimate authority to
resolve such claims is expressly retained by Purchaser and
Purchaser expressly retains the authority to make the ultimate
decision with regard to such claims. Purchaser also retains the
authority to decide whether an investigation of any disputed claim is
to be conducted and, if so, the extent of that investigation.
HPHC will administer the grievance and appeals procedure for
Members as described in Attachment E.
Lh.
3. Benefits Adminstration. HPHC will appropriately administer the
Purchaser's Benefit Option Code (BOC) as selected by the Purchaser. Any Level 1 or
Level 2 benefit package not covered by an existing BOC will be charged a set up fee of
one hundred dollars ($100.00) per hour for programming costs and seventy-five dollars
($75.00) per hour for installation costs associated with each request
4. Contracting Provider and Member Service Records. HPHC shall design,
implement and maintain the following services related to Contracting Provider and
Member services and records:
FORM# PS_AQ1
05/17/2002
