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2021-074B
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2021-074B
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Last modified
6/22/2021 12:13:29 PM
Creation date
6/11/2021 3:23:37 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
05/11/2021
Control Number
2021-074B
Agenda Item Number
12.D.1.
Entity Name
Employer Direct Healthcare, LLC
Subject
Surgeryplus Services Agreement
Addition of SurgeryPlus Benefit as Optional Benefit
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DocuSign Envelope ID: 29EAB906-1936-4BAB-83BE-97C974F00293 <br />for the delay. EDH shall approve or deny the claim within thirty (30) days of receiving <br />additional information, and, if the claim is approved, pay the claim within thirty (30) days of <br />receiving additional information. Interest on claims that are not paid shall equal prime rate <br />at the largest bank in Nevada as determined by the Commissioner of Financial Institutions on <br />January 1 or July 1, plus six percent (6%), calculated from thirty (30) days after the date on <br />which the claim is approved until the claim is paid. Claimants shall not be requested to <br />resubmit information already provided, unless a legitimate reason is provided and the <br />purpose is not to delay payment, harass the claimant, or discourage filing of claims. EDH shall <br />not pay only a part of a claim that has been approved and is fully payable. A court shall award <br />costs and reasonable attorney's fees to the prevailing party in an action brough pursuant to <br />this section. Payment of interest for the late payment of an approved claim may be waived <br />only if the payment was delayed because of an act of God or other cause beyond the control <br />of EDH. The Nevada Commission of Insurance may require EDH to provide evidence which <br />demonstrates that EDH has substantially complied with the requirements set forth in this <br />section, including payment within thirty (30) days or at least ninety-five percent (95%) of <br />approved claims or at least ninety percent (90%) of the total dollar amount for approved <br />claims. If the Nevada Commission of Insurance determines that EDH is not in substantial <br />compliance with the requirements set forth in this section, EDH may be required to pay an <br />administrative fine in an amount to be determine by the Nevada Commission of Insurance. <br />683A.088 Each claim paid by EDH from money collected for or on behalf of Sponsor must be paid by a <br />check or draft upon and as authorized by Sponsor. <br />683A.0883(1-2) (1) The compensation paid to EDH for its services may be based upon premiums or charges <br />collected, on number of claims paid or processed or on another basis agreed upon by EDH and <br />Sponsor, except as provided in subsection (2) below. <br />(2) Compensation paid to EDH may not be based upon or contingent upon: (a) The claim <br />experience of the policies which it handled; (b) The savings realized by EDH by adjusting, <br />settling or paying the losses covered by Sponsor <br />6. New Jersey: The Parties desire to supplement the Agreement to specifically reference certain <br />provisions of New Jersey law applicable to third party administrators and to comply with those laws to the <br />extent applicable and not preempted by federal law, as follows: <br />MRS 176:2713-6 <br />NJAC 11:23-3.1(b) <br />MRS 1713:2713-6(a) <br />NJAC 11:23-3.1(c)(1) <br />MRS 17B:27B-6(b) <br />NJAC 11:23-3.1(c)(2)(i) <br />MRS 17B:27B-6(b) <br />NJAC 11:23-3.1(c)(2)(ii) <br />NIRS 176:278-6(b) <br />NJAC 11-.23-3.1(c)(2)(iii) <br />The Agreement shall be retained as part of the official records of EDH for the <br />duration of the Agreement and for five years thereafter. <br />EDH will provide Sponsor the services described in the Agreement and will be <br />compensated as stated in the Agreement. <br />Sponsor will be responsible for the provision of enrollment and eligibility <br />information to EDH. <br />Sponsor will be responsible to EDH to arrange for a preliminary or escrowed <br />deposit of funds by Sponsor as described in the Agreement, if any. <br />Sponsor will be responsible for the transmittal of funds from Sponsor to EDH <br />for the purpose of paying claims as described in the Agreement. <br />�y <br />
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