Specifications include, but are not limited to: A. Plan Documents - Maintain a master file of plan documents, summary plan descriptions, plan booklets, benefit provisions, claims administration policies and guidelines, changes in plan benefits, and any other material needed to properly administer claims in accordance with the provisions of the plan applicable state and federal law. B. Eligibility - Maintain eligibility information to verify eligibility for benefits for plan participants and dependents. Eligibility to be transmitted electronically and/or manually, by the City or its designee. The administrator must maintain name and address files by employee and dependent. The administrator will also monitor and track the eligibility status of dependent children over the age of 26. C. CLAIMS PROCESSING 1. Review and examine claims (bills, invoices, and statements) submitted by plan participants or received from physicians, hospitals, pharmacies, labs, and any other eligible providers who have rendered care to eligible employees and their dependents. Procure any missing information immediately, by personal contact, telephone, or correspondence. 2. Determine reasonableness of charges and monitor the qualify, quantity, and utilization of professional, medical, and hospital care rendered, referring medical claims for “medical review” when necessary. 3. Process all appropriate claims as determined by the provisions of the plan documents and plan administrative policies/guidelines, utilizing the fee/reimbursement schedules established and provided by the City’s contracted network. Obtain timely updates of fee schedules and conversion factors. Accurate claims processing in a timely manner, according to performance standards. 4. Prepare/issue checks and itemized Explanation of Benefits forms to plan participants and providers. 5. Pend or deny claims not eligible for payment and issue related correspondence. Advise plan participants, dependents, or beneficiaries whose claims have been denied of the specific reasons for such denial, and the procedure for a review of the denial. Advise plan participants regarding the pending of a claim, the reasons for such action and the actions necessary to release the claim. D. CUSTOMER SERVICE 1. Provide professional, courteous, and timely responses to telephone, written, in-person inquiries and complaints from all sources. Such inquiries may include eligibility information, claims payment, benefit provisions, and related questions, from parties with authorized access to information such as plan participants, providers, legal counsel, the City, etc. 2. Furnish a toll-free telephone number for incoming customer service calls. Customer service personnel and/or call center shall be handled on-shore in the United States. 3. Provide assistance when requested with respect to special inquiries from the City which could arise involving claims processing for payment of claims.
