SCHEDULE B
TO
ADMINISTRATIVE SERVICES AGREEMENT
WITH
CITY OF NASHUA
This Schedule B shall govern the Agreement Period from July 1, 2013 through June 30, 2014. For purposes of this
Agreement Period, this Schedule B shall supplement and amend the Agreement between the Parties. If there are
any inconsistencies between the terms of the Agreement including any prior Schedules and this Schedule B, the
terms of this Schedule B shall control.
Additionaliy, at each renewal after September 23, 2010, Employer shall affirm in writing, upon reasonable
request of Anthem, that it has not made changes to its plan(s) that would cause the plan(s) to lose its/their
grandfathered status.
Anthem Health Plans of New Hampshire, Inc. dba
Anthem Blue Cross and Blue Shield
By:
Title:
Date:
Enterprise Administrative Services Agreement — October 2012 Master Template 25
City of Nashua 06/17/2013
B. Claims Runout Administrative Services Fees
Claims Runout Administrative Services Fees will be included in the Administrative Services Fee in Section
3(a) of this Schedule A.
Section 7. Other Amendments. The Administrative Services Agreement is otherwise amended as
follows:
BlueCard Program, Other Inter-Plan Programs and Non-Network Provider Fees
Article 3(a) Retroactive Adjustmenis to Enroliment.
Anthem shall credit Administrative Services Fees for each retroactive deletion up to a maximum of 60 days
and shall charge Administrative Services Fees for each retroactive addition up to a maximum of 60 days.
B. Optional Program Fees
Not Applicable
Cc. Other Fees or Credits
Fee for Independent Claims Review: $550.00 per independent review
Section 4. Paid Claims, Billing Cycle and Payment Method
A. Paid Claims
Not Applicable
SCHEDULE A
TO
ADMINISTRATIVE SERVICES AGREEMENT
WITH
CITY OF NASHUA
This Schedule A shall govern the Agreement Period from July 1, 2013 through June 30, 2014. For purposes of this
Agreement Period, this Schedule shall supplement and amend the Agreement between the Parties. If there are any
inconsistencies between the terms of the Agreement including any prior Schedules, and this Schedule A, the terms of
this Schedule A shall control.
Section 1. Effective Date and Renewal Notice
The Parties acknowledge that Anthem, in making decisions regarding the scope of coverage of services
under the Benefits Booklet, is not engaged in the practice of medicine. Providers are not restricted in
exercising their independent medical judgment by contract or otherwise and do not act on behalf of, or as
agents for, Anthem or the Plan.
d. Employer shall ensure that sufficient amounts are available to cover Claims payments, the monthly
Administrative Services Fee, and other fees or charges.
ARTICLE 25 - ENTIRE AGREEMENT
a. The following documents will constitute the entire Agreement between the Parties: this Agreement,
including any amendments and Schedules thereto, and the Benefits Booklet.
b. This Agreement may be executed simultaneously in two or more counterparts, each of which shall be
deemed an original, but all of which together shall constitute one and the same instrument.
ARTICLE 22 - ASSIGNMENT AND SUBCONTRACTING
Any deposit amount shall be paid to Anthem within 30 days of the request or in such shorter time as agreed
to by the Parties. The deposit amount shall not be paid with Plan assets, shall not be funded in any part by
Member contributions, and shall not be paid from any segregated fund or from funds in which the Plan or
any Member has a beneficial interest. The deposit amount shall be the property of Anthem, may be held in
Anthem's general account, may be subject to satisfy the claims of Anthem's general creditors, and does not
