Specifications include, but are not limited to: 1. Recommend changes to the Plan document to keep the Plan Document up to date and
compliant. Recommend reasonable policies, procedures, rules and interpretations to
promote orderly and efficient administration of this Agreement and the Plan.
2. Provide claims administrative services for Plan Sponsor with respect to claims presented
for payment during the term of this Agreement.
3. Provide information and assistance to Plan participants concerning claims for benefits
under the Plan. Provide explanation of benefits for payments made and for denial of
benefits. Provide claim forms and debit cards as needed.
4. Receive and process claims received after the Effective Date and pay or deny such claims
for benefits in accordance with the terms of the Plan Document.
5. Claims payments will be made by the Contractor from an account established by the
6. Share information with the State’s health plans and dental plans and coordinate claims for
the Health Savings Account participants.
7. If a Plan participant files a written request to the Contractor for a review of any claim
processed by the Contractor, the following procedure shall be implemented :
a. The Contractor will investigate the request and provide an appropriate written
response to the participant within thirty (30) days after date of receipt of the
request. Such response will include notification of a right of appeal.
b. In the event participant appeals to the Contractor, the Contractor will administer
those appeals, subject to the State’s final authority to determine issues which arise
under the plan.
8. Maintain records of coverage and claims histories of the Plan participants