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Optum <br />August 15, 2022 <br />STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS 1 RTIFYTHAT THIS IS A TRUE Ahjo CORRECT <br />COPY T ORIAIN ON F17N THIS ICE. <br />JEFF A. IIT E <br />BY D.C. <br />DATE <br />EASY REPORTING AGREEMENT <br />Indian River County Board of County Commissioners <br />Upon receipt of your signature below, Optum will implement Easy Reporting for potential <br />Specific claims. The following will apply: <br />Optum will identify claims for reimbursement as a courtesy based on detailed paid claim <br />reports submitted by the Administrator(s) and/or PBM(s). Please note that responsibility for <br />identifying and submitting claims remains the Client's responsibility. <br />Optum will reach out to the designated stop loss contact(s) on file, if necessary, to obtain <br />additional information, including, but not limited to: <br />- Eligibility documentation, work status, COBRA <br />- Other insurance coverage <br />- Accident details/subrogation <br />- Any other information deemed necessary in order to fully adjudicate the stop loss claim <br />Claim submissions whether identified by the Administrator(s), the Client, the Broker or <br />Optum will be subject to the timely filing provision as outlined in the stop loss policy. All <br />claim submissions/paid claim reports must be submitted within 12 months after the end of <br />the Benefit Period in order to be eligible for reimbursement under the stop loss policy. <br />This agreement may be term inated,,4, .W'. -.Optum upon written notice. <br />;�Jd� 1�0 <br />Signature of Authorized Pers <br />Peter D. O'Bryan +•9?9��fRCOIlN,rltle: Chairman <br />Printed Name <br />September 13, 2022 <br />Date RPPA0VED NE) 70 FORM <br />Attest: Jeffrey R. Smith, Clerk of BY W =.o_.•�.. <br />Circuit Court and Comptroller _ ;'a.�! i`' <br />00UN11YaM-TORNEY <br />ar: <br />Deputy Clerk <br />