2023-098B - Laserfiche WebLink

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amount shall be credited to the Employer except as otherwise provided in Exhibit B. The Employer shall hold BCBSF and the Designated Agent harmless for any such payment not recovered. (6) Benefit Determination: The determination of the extent of the benefit to which any claimant is entitled under the Plan shall initially rest with BCBSF or the Designated Agent. BCBSF shall have no liability for alleged misinterpretations of the Plan of Benefits. In the event of a conflict between the Benefit Detail Report and the Plan of Benefits, the Benefit Detail Report shall control. (7) Determination of Eligibility: every member designated by the Employer to the Designated Agent shall be eligible for coverage. (8) Enrollment: the Designated Agent will enroll and maintain enrollment for members. Benefits will be paid pursuant to records supplied by Employer. (9) Recovery Services: (a) If BCBSF becomes aware of a potential recovery made under the Plan of Benefits, BCBSF or its Designated Agent may use its standard recovery processes and procedures to identify and attempt to recover any such amount(s). These standard recovery services are included in the Administrative Fee listed in Exhibit B. Notwithstanding the foregoing, in the event a recovery is made by a Host Plan, such Host Plan may charge a fee for its recovery services and any such fee shall be reflected on the Employer's invoice. (b) BCBSF or its Designated Agent, in its sole discretion, shall settle and resolve any recoveries pursued under this section II A 9 (b) on any basis it determines is reasonable including through offset against any amounts owed by Designated Agent to a member, provider or Employer as applicable (provided that BCBSF or its Designated Agent may only pursue litigation in accordance with Section II. A. 9 (c), including payment of less than the entire amount. (c) Notwithstanding the foregoing, BCBSF is not required to initiate court proceedings to comply with Section II, A. 9 (a) and (b). However, if BCBSF determines that litigation is necessary to recover the amount at issue, BCBSF or its Designated Agent will notify Employer, and Employer will be solely responsible for the decision to pursue litigation and funding all litigation costs and expenses, including attorney's fees. (d) In addition to the standard recovery services provided pursuant to Section II A. BCBSF or its Designated Agent offers additional recovery service options for additional fees. If Employer selects an option, the Enhanced Recovery Fee will be specified in the Exhibit B. (e) Any Coordination of Benefits refunds or third -party liability amounts received or recovered by Employer's Plan (including any amounts received as a result of any subrogation action by Employer or by BCBSF on behalf of the Plan) shall be used to reimburse BCBSF for any amount that it may have paid or become liable to pay Employer under the Stop -Loss Insurance. Thereafter, any remaining coordination of Benefits refunds or third -party liability amounts will be credited to Employer. 10