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City Clerk Document No.
City Council Meeting Date: October 27, 2022
CITY OF CHANDLER SERVICES AGREEMENT
GROUP MEDICAL AND PHARMACY PROGRAM ADMINISTRATION
CITY OF CHANDLER AGREEMENT NO. HR2-948-4453
THIS AGREEMENT (Agreement) is made and entered into by and between the City of Chandler, an
Arizona municipal corporation (City), and Blue Cross Blue Shield of Arizona, an Arizona non-profit
corporation and an independent licensee of the Blue Cross Blue Shield Association (Contractor),
(City and Contractor may individually be referred to as Party and collectively referred to as Parties)
and made
, 2022 (Effective Date).
RECITALS
A. City proposes to enter an agreement for group medical and pharmacy program administration
services as more fully described in Exhibit A, which is attached to and made a part of this Agreement
by this reference.
B. Contractor is ready, willing, and able to provide the services described in Exhibit A for the
compensation and fees set forth and as described in Exhibit B, which is attached to and made a part
of this Agreement by this reference.
C. City desires to contract with the Contractor to provide these services under the terms and
conditions set forth in this Agreement.
AGREEMENT
NOW, THEREFORE, in consideration of the premises and the mutual promises contained in this
Agreement, City and Contractor agree as follows:
SECTION I: DEFINITIONS
For purposes of this Agreement, the following definitions apply:
Agreement means the legal agreement executed between the City and the Contractor
City means the City of Chandler, Arizona
Contractor means the individual, partnership, or corporation named in the Agreement
Days means calendar days
May, Should means something that is not mandatory but permissible
Shall, Will, Must means a mandatory requirement
SECTION II: CONTRACTOR’S SERVICES
Contractor must perform the services described in Exhibit A to the City’s satisfaction within the
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terms and conditions of this Agreement and within the care and skill that a person who provides
similar services in Chandler, Arizona exercises under similar conditions. All work or services
furnished by Contractor under this Agreement must be performed in a skilled and workmanlike
manner. Unless authorized by the City in writing, all fixtures, furnishings, and equipment furnished
by Contractor as part of the work or services under this Agreement must be new, or the latest
model, and of the most suitable grade and quality for the intended purpose of the work or service.
SECTION III: PERIOD OF SERVICE
Contractor must perform the services described in Exhibit A for the term of this Agreement.
The term of the Agreement is two years, and begins on January 1, 2023, and ends on December 31,
2024, unless sooner terminated in accordance with the provisions of this Agreement. The City and
the Contractor may mutually agree to extend the Agreement for up to three additional terms of two
years each, or portions thereof. The City reserves the right, at its sole discretion, to extend the
Agreement for up to 60 days beyond the expiration of any extension term.
This Period of Service is controlling and shall prevail over any differing term related to the term of
the Agreement in any other Exhibit or Attachment incorporated into the Agreement.
SECTION lV: PAYMENT OF COMPENSATION AND FEES
Unless amended in writing by the Parties, Contractor's compensation and fees as more fully
described in Exhibit B for performance of the services approved and accepted by the City under this
Agreement must not exceed $2,190,000 per year for the fixed costs of administrative and stop loss
fees for the first term. Contractor must submit requests for payment for services approved and
accepted during the previous billing period and must include, as applicable, detailed invoices and
receipts, a narrative description of the tasks accomplished during the billing period, a list of any
deliverables submitted, and any subcontractor’s or supplier’s actual requests for payment plus
similar narrative and listing of their work. Payment for those services negotiated as a lump sum will
be made in accordance with the percentage of the work completed during the preceding billing
period. Services negotiated as a not-to-exceed fee will be paid in accordance with the work
completed on the service during the preceding month. All requests for payment must be submitted
to the City for review and approval. The City will make payment for approved and accepted services
within 30 days of the City’s receipt of the request for payment. Contractor bears all responsibility
and liability for any and all tax obligations that result from Contractor’s performance under this
Agreement.
All prices offered herein shall be firm against any increase for the initial term of the Agreement.
Prior to commencement of subsequent renewal terms, the City may approve a fully documented
request for a price adjustment. The City shall determine whether any requested price increases for
extension terms is acceptable to the City. If the City approves the price increase, the price shall
remain firm for the renewal term for which it was requested. If a price increase is agreed upon by
the Parties a written Agreement Amendment shall be approved and executed by the Parties. For
each renewal period, the renewal administrative fee increases will not exceed 3% of the current
administrative fees.
SECTION V: GENERAL CONDITIONS
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5.1 Records/Audits.
a. Audit. Upon reasonable prior written notice to Contractor and as mutually agreed upon during
Contractor’s normal working hours, the City may conduct the following audits at its own cost:
•
An audit of up to 50 claims as may be necessary to validate financial statements and which
occurs no more than one time per calendar year; and
•
An audit of the records of payments made to Providers and other data specifically related to
Contractor’s performance under this Agreement which occurs no more than once every two
calendar years.
The City agrees that any third-party auditor used to conduct the above audits shall not be
compensated on a percent of savings basis. For the number of type of audits specified above,
Contractor agrees to provide reasonable assistance and information to the City’s auditors
without charge. There is an additional charge for Contractor’s assistance with any audits
approved by Contractor beyond those specified. Any audit for any plan year must be both
commenced and finalized within twelve (12) months of the last day of the plan year being
audited; and (b) the termination of this Agreement. Contractor shall have no liability to pay the
City any amounts as a result of any audit unless demand for payment based on such audit is
received by Contractor within twelve (12) months of the end of the plan year in which the claim
was paid or denied.
b. Records. Contractor will retain electronic or paper copies of its claims for Participant’s for a
minimum of seven (7) years after such records’ creation or receipt by BCBSAZ. The obligation to
retain records as stated in this Section shall not apply to any records that Contractor returns to
the City, nor with respect to any records for which the City has duplicate copies. The City
acknowledges and agrees that at the end of seven (7) years’ retention of records as stated
herein, Contractor may destroy any such records without any obligation to provide prior notice
of such destruction to the City.
5.2 Alteration in Character of Work. Whenever an alteration in the character of work results in a
substantial change in this Agreement, thereby materially increasing or decreasing the scope of
services, cost of performance, or Project schedule, the work will be performed as directed by the
City. However, before any modified work is started, a written amendment must be approved and
executed by the City and the Contractor. Such amendment must not be effective until approved by
the City. Additions to, modifications, or deletions from this Agreement as provided herein may be
made, and the compensation to be paid to the Contractor may accordingly be adjusted by mutual
agreement of the Parties. It is distinctly understood and agreed that no claim for extra work done
or materials furnished by the Contractor will be allowed by the City except as provided herein, nor
must the Contractor do any work or furnish any materials not covered by this Agreement unless
such work is first authorized in writing. Any such work or materials furnished by the Contractor
without prior written authorization will be at Contractor's own risk, cost, and expense, and
Contractor hereby agrees that without written authorization Contractor will make no claim for
compensation for such work or materials furnished.
5.3 Termination for Convenience. The City and the Contractor hereby agree to the full
performance of the covenants contained herein, except that the City reserves the right, at its
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discretion and without cause, to terminate or abandon any service provided for in this
Agreement, or abandon any portion of the Project for which services have been performed by
the Contractor. In the event the City abandons or suspends the services, or any part of the
services as provided in this Agreement, the City will notify the Contractor in writing and
immediately after receiving such notice, the Contractor must discontinue advancing the work
specified under this Agreement. Upon such termination, abandonment, or suspension, the
Contractor must deliver to the City all drawings, plans, specifications, special provisions,
estimates and other work entirely or partially completed, together with all unused materials
supplied by the City. The Contractor must appraise the work Contractor has completed and
submit Contractor's appraisal to the City for evaluation. The City may inspect the Contractor's
work to appraise the work completed. The Contractor will receive compensation in full for
services performed to the date of such termination. The fee shall be paid in accordance with
Section IV of this Agreement, and as mutually agreed upon by the Contractor and the City. If
there is no mutual agreement on payment, the final determination will be made in accordance
with the Disputes provision in this Agreement. However, in no event may the payment exceed
the payment set forth in this Agreement nor as amended in accordance with Alteration in
Character of Work. The City will make the final payment within 60 days after the Contractor has
delivered the last of the partially completed items and the Parties agree on the final payment.
If the City is found to have improperly terminated the Agreement for cause or default, the
termination will be converted to a termination for convenience in accordance with the
provisions of this Agreement.
5.4 Termination for Cause. The City may terminate this Agreement for Cause upon the occurrence
of any one or more of the following events: in the event that (a) the Contractor fails to perform
pursuant to the terms of this Agreement, (b) the Contractor is adjudged a bankrupt or insolvent, (c)
the Contractor makes a general assignment for the benefit of creditors, (d) a trustee or receiver is
appointed for Contractor or for any of Contractor’s property (e) the Contractor files a petition to
take advantage of any debtor's act, or to reorganize under the bankruptcy or similar laws, (f) the
Contractor disregards laws, ordinances, rules, regulations or orders of any public body having
jurisdiction, or (g) the Contractor fails to cure default within the time requested. Where Agreement
has been so terminated by City, the termination will not affect any rights of City against Contractor
then existing or which may thereafter accrue.
5.5 Indemnification by Contractor. Contractor shall indemnify, defend, save and hold harmless
the City and its officers, officials, agents, and employees (hereinafter referred to as
“Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or
expenses (including court costs, attorneys’ fees, and costs of claims processing, investigation
and litigation) (hereinafter referred to as “Claims”) caused, or alleged to be caused, in whole or
in part, by the negligent or willful acts or omissions of the Contractor or any of its owners,
officers, directors, agents, employees or subcontractors. This indemnity includes any claim or
amount arising out of or recovered under the Worker’s Compensation Law or arising out of the
failure of such Contractor to conform to any federal, state or local law, statute, ordinance, rule,
regulation or court decree. It is the specific intention of the parties that the “Indemnitee” shall,
in all instances, except for Claims arising solely from the negligent or willful acts or omissions
of the “Indemnitee”, be indemnified by the Contractor from and against any and all claims. It is
agreed that the Contractor will be responsible for primary loss investigation, defense, and
judgement costs where this indemnification is applicable. In consideration of the award of this
Agreement, the Contractor agrees to waive all rights of subrogation against the City, its officers,
officials, agents, and employees for losses arising from the work performed by the Contractor
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for the City. The obligations of the Contractor under this provision survive the termination or
expiration of this Agreement and shall remain in full force and effect after the date of
termination or expiration.
Indemnification by the City. The City shall indemnify, hold harmless, and defend the Contractor,
its directors, officers, employees, or agents from and against any and all actions, causes of
action, suits, claims, judgements, settlements, liabilities, damages, penalties, losses and/or
expenses, and costs, including, without limitation, attorneys’ fees, punitive and exemplary
damages, resulting directly from or arising solely out of negligent or willful acts or omissions of
the City, its directors, officers, employees, or agents. This indemnification obligation shall
survive the termination or expiration of this Agreement and shall remain in full force and effect
after the date of termination or expiration.
The indemnification provisions in this section apply to the entire Agreement between the Parties
and shall prevail over any differing terms related to indemnification by the Contractor or the City in
any other Exhibit or Attachment incorporated into the Agreement.
5.6 Insurance Requirements. Contractor must procure insurance under the terms and
conditions and for the amounts of coverage set forth in Exhibit C against claims that may arise
from or relate to performance of the work under this Agreement by Contractor and its agents,
representatives, employees, and subcontractors. Contractor and any subcontractors must
maintain this insurance until all of their obligations have been discharged, including any
warranty periods under this Agreement. These insurance requirements are minimum
requirements for this Agreement and in no way limit the indemnity covenants contained in this
Agreement. The City in no way warrants that the minimum limits stated in Exhibit C are
sufficient to protect the Contractor from liabilities that might arise out of the performance of
the work under this Agreement by the Contractor, the Contractor’s agents, representatives,
employees, or subcontractors. Contractor is free to purchase such additional insurance as may
be determined necessary.
5.7 Cooperation and Further Documentation. The Contractor agrees to provide the City such
other duly executed documents as may be reasonably requested by the City to implement the
intent of this Agreement.
5.8 Notices. Unless otherwise provided, notice under this Agreement must be in writing and
will be deemed to have been duly given and received either (a) on the date of service if
personally served on the party to whom notice is to be given, or (b) on the date notice is sent if
by electronic mail, or (c) on the third day after the date of the postmark of deposit by first class
United States mail, registered or certified, postage prepaid and properly addressed as follows:
For the City
For the Contractor
Name: Christina Pryor Name: Christie Thomas
Title: Purchasing Manager Title:
Strategic Relationship Executive
Address: 175 S. Arizona Ave., 3rd Floor Address: 2444 W. Palmaritas Drive
Chandler, AZ 85225
Phoenix, AZ 85021
Phone: 480-782-2403 Phone: 602-864-5234
Email: christina.pryor@chandleraz.gov Email: christie.thomas@azblue.com
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5.9 Successors and Assigns. City and Contractor each bind itself, its partners, successors,
assigns, and legal representatives to the other party to this Agreement and to the partners,
successors, assigns, and legal representatives of such other party in respect to all covenants of
this Agreement. Neither the City nor the Contractor may assign, sublet, or transfer its interest
in this Agreement without the written consent of the other party. In no event may any
contractual relation be created between any third party and the City.
5.10 Disputes. In any dispute arising out of an interpretation of this Agreement or the duties
required not disposed of by agreement between the Contractor and the City, the final
determination at the administrative level will be made in accordance with standard rules of
contract construction and interpretation and applicable statutes, regulations, and codes.
5.11 Completeness and Accuracy of Contractor's Work. The Contractor must be responsible for
the completeness and accuracy of Contractor's services, data, and other work prepared or
compiled under Contractor's obligation under this Agreement and must correct, at Contractor's
expense, all willful or negligent errors, omissions, or acts that may be discovered. The fact that
the City has accepted or approved the Contractor's work will in no way relieve the Contractor
of any of Contractor's responsibilities.
5.12 Withholding Payment. The City reserves the right to withhold funds from the Contractor's
payments up to the amount equal to the claims the City may have against the Contractor until
such time that a settlement on those claims has been reached.
5.13 City's Right of Cancellation. The Parties acknowledge that this Agreement is subject to
cancellation by the City under the provisions of Section 38-511, Arizona Revised Statutes
(A.R.S.).
5.14 Independent Contractor. For this Agreement the Contractor constitutes an independent
contractor. Any provisions in this Agreement that may appear to give the City the right to direct
the Contractor as to the details of accomplishing the work or to exercise a measure of control
over the work means that the Contractor must follow the wishes of the City as to the results of
the work only. These results must comply with all applicable laws and ordinances.
5.15 Project Staffing. Prior to the start of any work under this Agreement, the Contractor must
assign to the City the key personnel that will be involved in performing services prescribed in
the Agreement. The City may acknowledge its acceptance of such personnel to perform
services under this Agreement. At any time hereafter that the Contractor desires to change key
personnel while performing under the Agreement, the Contractor must submit the
qualifications of the new personnel to the City for prior approval. The Contractor will maintain
an adequate and competent staff of qualified persons, as may be determined by the City,
throughout the performance of this Agreement to ensure acceptable and timely completion of
the Scope of Services. If the City objects, with reasonable cause, to any of the Contractor's staff,
the Contractor must take prompt corrective action acceptable to the City and, if required,
remove such personnel from the Project and replace with new personnel agreed to by the City.
5.16 Subcontractors. Prior to beginning the work, the Contractor must furnish the City the
names of subcontractors to be used under this Agreement. The Contractor agrees to obtain
City’s written consent prior to entering into any subcontract for services to be performed for
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the City. For purposes of this provision, the following are not considered subcontracts:
contracts between Contractor and any health care provider or any third party administrator
reimbursement entity, or any specially contracted health care provider arrangement.
5.17 Force Majeure. If either party is delayed or prevented from the performance of any act
required under this Agreement by reason of acts of God or other cause beyond the control and
without fault of the Party (financial inability excepted), performance of that act may be excused,
but only for the period of the delay, if the Party provides written notice to the other Party within
ten days of such act. The time for performance of the act may be extended for a period
equivalent to the period of delay from the date written notice is received by the other Party.
5.18 Compliance with Laws. Contractor understands, acknowledges, and agrees to comply with
the Americans with Disabilities Act, the Immigration Reform and Control Act of 1986 and the
Drug Free Workplace Act of 1989. All services performed by Contractor must also comply with
all applicable City of Chandler codes, ordinances, and requirements. Contractor agrees to
permit the City to verify Contractor’s compliance.
5.19 No Israel Boycott. By entering into this Agreement, Contractor certifies that Contractor is
not currently engaged in, and agrees for the duration of the Agreement, not to engage in a
boycott of Israel as defined by state statute.
5.20 Legal Worker Requirements. A.R.S. § 41-4401 prohibits the City from awarding a contract
to any contractor who fails, or whose subcontractors fail, to comply with A.R.S. § 23-214(A).
Therefore, Contractor agrees Contractor and each subcontractor it uses warrants their
compliance with all federal immigration laws and regulations that relate to their employees
and their compliance with§ 23-214, subsection A. A breach of this warranty will be deemed a
material breach of the Agreement and may be subject to penalties up to and including
termination of the Agreement. City retains the legal right to inspect the papers of any
Contractor’s or subcontractor’s employee who provides services under this Agreement to
ensure that the Contractor and subcontractors comply with the warranty under this provision.
5.21 Forced Labor of Ethnic Uyghurs Prohibited. By entering into this Agreement, Contractor
certifies under A.R.S. sec. 35-394 that Contractor does not currently and agrees for the duration
of the contract that Contractor will not use: (i) the forced labor of ethnic Uyghurs in the People's
Republic of China; or (ii) any goods or services produced by the forced labor of ethnic Uyghurs
in the People's Republic of China; or (iii) any contractors, subcontractors or suppliers that use
the forced labor or any goods or services produced by the forced labor of ethnic Uyghurs in
the People's Republic of China.
5.22 Lawful Presence Requirement. A.R.S. §§ 1-501 and 1-502 prohibit the City from awarding
a contract to any natural person who cannot establish that such person is lawfully present in
the United States. To establish lawful presence, a person must produce qualifying identification
and sign a City-provided affidavit affirming that the identification provided is genuine. This
requirement will be imposed at the time of contract award. This requirement does not apply
to business organizations such as corporations, partnerships, or limited liability companies.
5.23 Covenant Against Contingent Fees. Contractor warrants that no person has been
employed or retained to solicit or secure this Agreement upon an agreement or understanding
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for a commission, percentage, brokerage, or contingent fee, and that no member of the
Chandler City Council, or any City employee has any interest, financially, or otherwise, in
Contractor’s firm. For breach or violation of this warrant, the City may annul this Agreement
without liability or, at its discretion, to deduct from the Agreement price or consideration, the
full amount of such commission, percentage, brokerage, or contingent fee.
5.24 Non-Waiver Provision. The failure of either Party to enforce any of the provisions of this
Agreement or to require performance of the other Party of any of the provisions hereof must
not be construed to be a waiver of such provisions, nor must it affect the validity of this
Agreement or any part thereof, or the right of either Party to thereafter enforce each and every
provision.
5.25 Data Confidentiality and Data Security. As used in the Agreement, data means all
information, whether written or verbal, including plans, photographs, studies, investigations, audits,
analyses, samples, reports, calculations, internal memos, meeting minutes, data field notes, work
product, proposals, correspondence and any other similar documents or information prepared by,
obtained by, or transmitted to the Contractor or its subcontractors in the performance of this
Agreement. The Parties agree that all data, regardless of form, including originals, images, and
reproductions, prepared by, obtained by, or transmitted to the Contractor or its subcontractors in
connection with the Contractor's or its subcontractor’s performance of this Agreement is
confidential and proprietary information belonging to the City. Except as specifically provided in this
Agreement, Contractor or its subcontractors must not divulge data to any third party without the
City’s prior written consent. Contractor or its subcontractors must not use the data for any purposes
except to perform the services required under this Agreement. These prohibitions do not apply to
the following data provided to the Contractor or its subcontractors have first given the required
notice to the City: (a) data which was known to the Contractor or its subcontractors prior to its
performance under this Agreement unless such data was acquired in connection with work
performed for the City; or (b) data which was acquired by the Contractor or its subcontractors in its
performance under this Agreement and which was disclosed to the Contractor or its subcontractors
by a third party, who to the best of the Contractor's or its subcontractors knowledge and belief, had
the legal right to make such disclosure and the Contractor or its subcontractors are not otherwise
required to hold such data in confidence; or (c) data which is required to be disclosed by virtue of
law, regulation, or court order, to which the Contractor or its subcontractors are subject. In the event
the Contractor or its subcontractors are required or requested to disclose data to a third party, or
any other information to which the Contractor or its subcontractors became privy as a result of any
other contract with the City, the Contractor must first notify the City as set forth in this Section of
the request or demand for the data. The Contractor or its subcontractors must give the City
sufficient facts so that the City can be given an opportunity to first give its consent or take such
action that the City may deem appropriate to protect such data or other information from
disclosure. Unless prohibited by law, within ten calendar days after completion or termination of
services under this Agreement, the Contractor or its subcontractors must promptly deliver, as set
forth in this Section, a copy of all data to the City. All data must continue to be subject to the
confidentiality agreements of this Agreement. Contractor or its subcontractors assume all liability
to maintain the confidentiality of the data in its possession and agrees to compensate the City if any
of the provisions of this Section are violated by the Contractor, its employees, agents or
subcontractors. Solely for the purposes of seeking injunctive relief, it is agreed that a breach of this
Section must be deemed to cause irreparable harm that justifies injunctive relief in court. Contractor
agrees that the requirements of this Section must be incorporated into all subcontracts entered
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into by Contractor. A violation of this Section may result in immediate termination of this Agreement
without notice.
5.26 Personal Identifying Information-Data Security. Personal identifying information, financial
account information, or restricted City information, whether electronic format or hard copy,
must be secured and protected at all times by Contractor and any of its subcontractors. At a
minimum, Contractor must encrypt or password-protect electronic files. This includes data
saved to laptop computers, computerized devices, or removable storage devices. When
personal identifying information, financial account information, or restricted City information,
regardless of its format, is no longer necessary, the information must be redacted or destroyed
through appropriate and secure methods that ensure the information cannot be viewed,
accessed, or reconstructed. In the event that data collected or obtained by Contractor or its
subcontractors in connection with this Agreement is believed to have been compromised,
Contractor or its subcontractors must immediately notify the City contact. Contractor agrees
to reimburse the City for any costs incurred by the City to investigate potential breaches of this
data and, where applicable, the cost of notifying individuals who may be impacted by the
breach. Contractor agrees that the requirements of this Section must be incorporated into all
subcontracts entered into by Contractor. It is further agreed that a violation of this Section must
be deemed to cause irreparable harm that justifies injunctive relief in court. A violation of this
Section may result in immediate termination of this Agreement without notice. The obligations
of Contractor or its subcontractors under this Section must survive the termination of this
Agreement.
5.27 Jurisdiction and Venue. This Agreement is made under and must be construed in
accordance with and governed by the laws of the State of Arizona without regard to the
conflicts or choice of law provisions thereof. Any action to enforce any provision of this
Agreement or to obtain any remedy with respect hereto must be brought in the courts located
in Maricopa County, Arizona, and for this purpose, each Party hereby expressly and irrevocably
consents to the jurisdiction and venue of such court.
5.28 Survival. All warranties, representations, and indemnifications by the Contractor must
survive the completion or termination of this Agreement.
5.29 Modification. Except as expressly provided herein to the contrary, no supplement,
modification, or amendment of any term of this Agreement will be deemed binding or effective
unless in writing and signed by the Parties.
5.30 Severability. If any provision of this Agreement or the application to any person or
circumstance may be invalid, illegal or unenforceable to any extent, the remainder of this
Agreement and the application will not be affected and will be enforceable to the fullest extent
permitted by law.
5.31 Integration. This Agreement contains the full agreement of the Parties. Any prior or
contemporaneous written or oral agreement between the Parties regarding the subject matter
is merged and superseded.
5.32 Time is of the Essence. Time of each of the terms, covenants, and conditions of this
Agreement is hereby expressly made of the essence.
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5.33 Date of Performance. If the date of performance of any obligation or the last day of any
time period provided for should fall on a Saturday, Sunday, or holiday for the City, the
obligation will be due and owing, and the time period will expire, on the first day after which is
not a Saturday, Sunday or legal City holiday. Except as may otherwise be set forth in this
Agreement, any performance provided for herein will be timely made if completed no later
than 5:00 p.m. (Chandler time) on the day of performance.
5.34 Delivery. All prices are F.O.B. Destination and include all delivery and unloading at the
specified destinations. The Contractor will retain title and control of all goods until they are
delivered and accepted by the City. All risk of transportation and all related charges will be the
responsibility of the Contractor. All claims for visible or concealed damage will be filed by the
Contractor. The City will notify the Contractor promptly of any damaged goods and will assist
the Contractor in arranging for inspection.
5.35 Third Party Beneficiary. Nothing under this Agreement will be construed to give any rights
or benefits in the Agreement to anyone other than the City and the Contractor, and all duties
and responsibilities undertaken pursuant to this Agreement will be for the sole and exclusive
benefit of City and the Contractor and not for the benefit of any other party.
5.36 Conflict in Language. All work performed must conform to all applicable City of Chandler
codes, ordinances, and requirements as outlined in this Agreement. If there is a conflict in
interpretation between provisions in this Agreement and those in the Exhibits, the provisions
in this Agreement prevail.
5.37 Document/Information Release. Documents and materials released to the Contractor,
which are identified by the City as sensitive and confidential, are the City’s property. The
document/material must be issued by and returned to the City upon completion of the services
under this Agreement. Contractor’s secondary distribution, disclosure, copying, or duplication
in any manner is prohibited without the City’s prior written approval. The document/material
must be kept secure at all times. This directive applies to all City documents, whether in
photographic, printed, or electronic data format.
5.38 Exhibits and Order of Precedence. The below-listed exhibits are made a part of this
Agreement and are incorporated by reference as if fully set forth herein.
1. This Services Agreement
2. Exhibit A - Project Description/Scope of Services, including:
a. Exhibit A 1 – BCBSAZ City of Chandler Best and Final Offer
b. Exhibit A 2 – BCBSAZ Response to RFP Exhibit A and Questionnaire Parts A and B
c. Exhibit A 3 – BCBSAZ Services Included in Administrative Fees
d. Exhibit A 4 – BCBSAZ Subcontractor List
e. Exhibit A 5 – BCBSAZ Proposed Implementation Timeline
f. Exhibit A 6 – BCBSAZ Specialty Drug List
g. Exhibit A 7 – BCBSAZ Audit Requirements
h. Exhibit A 8 – BCBSAZ Pharmacy Claims Excluded from Guarantees
3. Exhibit B - Compensation and Fees
a. Exhibit B 1 Medical Worksheet City of Chandler BAFO
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b. Exhibit B 2 RX Worksheet City of Chandler BAFO
c. Exhibit B 3 – City of Chandler Renewal Rates and Assumptions
d. Exhibit B 4 – Pharmacy Pricing Grid Pass Through 2023
e. Exhibit B 5 – HSA Employer and Account Holder Fees
4. Exhibit C - Insurance Requirements
5. Exhibit D - Special Conditions
6. Exhibit E – BCBSAZ Stop Loss Agreement
7. Exhibit F – BCBSAZ Administrative Services Agreement
8. Exhibit G - Supplemental Terms and Conditions to Administrative Services Agreement
a. Exhibit G 1 – Exhibit A to ASA Terms: Blue Card (HMO Plans)/(PPO Plans)
b. Exhibit G 2 - Attachment A to Administrative Services Agreement Terms
Precedence. Any conflict between and among the terms and conditions of this Agreement and its
Exhibits, or any ambiguity created thereby, shall be resolved in accordance with the following
descending order of precedence:
1. The Services Agreement including Exhibits A through D (including subparts)
2. Exhibit E – Stop Loss Agreement
3. Exhibit F and G (including subparts) – ASA with Supplemental Terms and Conditions,
including Exhibit A and Attachment A
5.39 Special Conditions. As part of the services Contractor provides under this Agreement,
Contractor agrees to comply with and fully perform the special terms and conditions set forth
in Exhibit D, which is attached to and made a part of this Agreement.
5.40 Cooperative Use of Agreement. In addition to the City of Chandler and with approval of
the Contractor, this Agreement may be extended for use by other municipalities, school
districts and government agencies of the State. Any such usage by other entities must be in
accordance with the ordinance, charter and/or procurement rules and regulations of the
respective political entity.
If required to provide services on a school district property at least five times during a month,
the Contractor will submit a full set of fingerprints to the school of each person or employee
who may provide such service. The District will conduct a fingerprint check in accordance with
A.R.S. 41-1750 and Public Law 92-544 of all Contractors, subcontractors or vendors and their
employees for which fingerprints are submitted to the District. Additionally, the Contractor will
comply with the governing body fingerprinting policies of each individual school district/public
entity. The Contractor, sub-contractors, vendors and their employees will not provide services
on school district properties until authorized by the District.
Orders placed by other agencies and payment thereof will be the sole responsibility of that
agency. The City will not be responsible for any disputes arising out of transactions made by
other agencies who utilize this Agreement.
5.41 Non-Discrimination and Anti-Harassment Laws. Contractor must comply with all
applicable City, state, and federal non-discrimination and anti-harassment laws, rules, and
regulations.
5.42 Licenses and Permits. Beginning with the Effective Date and for the full term of this
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Agreement, Contractor must maintain all applicable City, state, and federal licenses and
permits required to fully perform Contractor’s services under this Agreement.
5.43 Warranty of Performance. Contractor warrants that it will perform the work and services
set forth in the Scope of Services in a professional and workmanlike manner, in conformity with
the specification and requirements of this Agreement, in accordance with generally accepted
professional standards, and in compliance with all applicable laws, rules, and regulations. Such
warranty of performance shall extend for twelve (12) months from the date of the performance
of the work.
5.44 Emergency Purchases. City reserves the rights to purchase from other sources those
items, which are required on an emergency basis and cannot be supplied immediately by the
Contractor.
5.45 Non-Exclusive Agreement. This agreement is for the sole convenience of the City of
Chandler. The City reserves the right to obtain like goods or services from another source when
necessary.
5.46 Budget Approval Into Next Fiscal Year. This Agreement will commence on the Effective Date
and continue in full force and effect until it is terminated or expires in accordance with the
provisions of this Agreement. The Parties recognize that the continuation of this Agreement after
the close of the City's fiscal year, which ends on June 30 of each year, is subject to the City Council's
approval of a budget that includes an appropriation for this item as expenditure. The City does not
represent that this budget item will be actually adopted. This determination is solely made by the
City Council at the time Council adopts the budget.
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This Agreement shall be in full force and effect only when it has been approved and executed
by the duly authorized City officials.
FOR THE CITY
FOR THE CONTRACTOR
By: _________________________________________
By: _________________________________________
Its: Mayor
Its: _________________________________________
APPROVED AS TO FORM:
By: _________________________________________
City Attorney
ATTEST:
By: _________________________________________
City Clerk
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Vice President, Commercial Sales
Exhibit A
Scope of Services
The Contractor shall provide the following services consistent with the Contractor’s response to RFP
No. HR2-948-4453, as confirmed and clarified by the Contractor’s Best and Final Offer dated June 9,
2022.
The Contractor will provide medical plan administration services including:
Account Management
▪
Provide a designated Account Manager and Account Management Team
Secure Internet Access
▪
Access to Claims Administration Portal for Employees to view claim status, EOB’s, etc.
▪
Employer and/or Designated Consultant access to Claims Data Reporting Portal to view and
download online reports.
Customer Service
▪
Provide concierge customer service to answer inquiries on claims, eligibility, provider network,
services, coverage, or other inquiries Monday through Friday from 8:00 AM to 6:00 PM (AZ time).
Open Enrollment Support
▪
Prepare and provide Benefit Presentations in collaboration with the City
▪
Attend Open Enrollment Meetings
Meeting Attendance
▪
Attend meetings as required and requested by the City
Telehealth
▪
Provide 24/7 telehealth services for medical, counseling, or psychiatry services.
Telemedicine
▪
Provide virtual office visits in lieu of physical office visit with a member’s doctor.
Communication/Education Materials
▪
Provide bilingual communication/educational materials
▪
Provide Booklets/Certificates and Identification Card generation
Claims Administration
▪
Provide claims forms
▪
Receive claims and process payments of benefits in accordance with the plan designs
▪
Correspond with participants and providers if additional information is necessary to complete the
processing of claims
▪
Determine, based on the City’s medical necessity guidelines, benefits payable under the Plan,
pursuant to the terms and conditions of the City’s Benefit Plan
▪
Coordinate benefits payable under the Plan and with other benefit plans, if applicable
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▪
Provide notice to the Participants regarding the reason(s) for denial of benefits (which are denied)
and provide for the review of such denied claims
▪
Provide an explanation of benefits resulting from claims transactions to plan participants
▪
Provide SBCs
▪
Perform Recovery of Payments of $25 or more
▪
Administer a Fraud and Abuse Detection Program
▪
Provide Full Claims Fiduciary Services (all levels of appeals – no litigation)
Eligibility/Enrollment Administration
▪
Administer eligibility based on the City’s eligibility criteria
▪
Accept electronic eligibility files from the City’s Benefits Administration system.
Reporting
▪
Provide reporting of all benefits being administered as detailed in the Reporting section of the
Questionnaire.
The Contractor will provide Medical Case Management, Utilization Review, and Disease
Management services including:
Utilization Management (UM) including Precertification Services
▪
Provide precertification and utilization management services in accordance with the City’s plan
document.
Concurrent Review
▪
Determine the appropriateness and level of care for ongoing stays. Since most of the ongoing stays
for the current network is contracted with a DRG reimbursement, concurrent review is established
if a member moves to a lower level of care that is reimbursed on a per diem basis such as long-term
acute care, skilled nursing, or inpatient rehabilitation.
Comprehensive Case Management (CM) Program
▪
Assist participants to learn more about their illness and risk factors and understand treatment
options and expected outcomes.
▪
Understand and wisely use their health benefits and case management services
▪
Access other resources outside their insurance plan
▪
Avoid more expensive care or duplication of services
▪
Coordinate services among many different providers
Disease Management Programs
▪
Asthma
▪
Chronic Obstructive Pulmonary Disease (COPD)
▪
Diabetes (Type 1 and 2)
▪
Coronary Artery Disease (CAD)
▪
Congestive Heart Failure
Claim and UM Appeals
▪
Handle all levels of the Appeal Process for services provided. (no litigation)
Preferred Provider Organization (PPO) Network Access
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▪
Provide a comprehensive PPO provider network with competitive discounts for Arizona
participants as well as any out-of-state participants.
▪
Provide a network that includes a sufficient number of providers for acute hospitals, health care
professionals, ancillary providers such as durable medical equipment, skilled nursing facility,
home health, rehabilitation, hospice, transplant centers of excellence, and behavioral health
providers.
Pharmacy Benefit Manager
Provide comprehensive PBM services including, but not limited to, the following:
▪
Claims adjudication
▪
Ability to Integrate PBM services with other vendors (e.g. Disease Management, Care
Management, Medical), if applicable
▪
Eligibility Maintenance
▪
Patient and Provider Education
▪
Systematic Prospective, Concurrent, and Retrospective Drug Utilization Review
▪
Network Pharmacy Management
▪
Formulary Management and Rebate Sharing
▪
Data Reporting (standard and ad-hoc reporting)
▪
Distribution of ID Cards and Pharmacy Directories
▪
Mail Service Pharmacy
▪
Specialty Pharmacy Program
▪
Complete Availability of IT services, including Online/Real Time Availability to the District and/or its
designee(s)
▪
Pricing Administration
▪
Member Services, including quality and functionality of member website and mobile app
▪
Ad Hoc Reporting
▪
Clinical Programs
Wellness Benefits Administration
▪
Online Health Risk Assessment
▪
24/7 Nurseline
▪
24/7 and Online Lifestyle Management Program (including challenges, coaching, and wellness
programs)
▪
Maternity/Healthy Baby Program
▪
Onsite Health and Wellness Fair Support
▪
Flu Shots – Onsite Discounted Services
Discount Services
Provide discounted programs for participants that include:
▪
Wireless-Enabled Wearable Technology Device
▪
Weight Loss Programs
▪
Vitamins
▪
Gym Memberships
▪
Apparel
Stop Loss
Stop-Loss includes:
▪
Incurred in 12 months and Paid in 24 months (12/24)
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▪
Lifetime maximum benefit is unlimited
▪
Coverage is for Medical and Prescription Drug only
▪
$350,000 annual specific deductible per individual
▪
Aggregating Stop Loss of 125%
▪
Retirees are covered
Interface and Coordination with City’s Vendors and Service Providers
As-needed, when needed.
Contractor shall provide the above services as described, confirmed, clarified, or limited in the following
exhibits incorporated hereby into the Scope of Services:
Exhibit A 1 – BCBSAZ City of Chandler Best and Final Offer
Exhibit A 2 – BCBSAZ Response to RFP Exhibit A and Questionnaire Parts A and B
Exhibit A 3 – BCBSAZ Services Included in Administrative Fees
Exhibit A 4 – BCBSAZ Subcontractor List
Exhibit A 5 – BCBSAZ Proposed Implementation Timeline
Exhibit A 6 – BCBSAZ Specialty Drug List
Exhibit A 7 – BCBSAZ Audit Requirements
Exhibit A 8 – BCBSAZ Pharmacy Claims Excluded from Guarantees
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Exhibit A 1
BCBSAZ City of Chandler Best and Final Offer
M E M O R A N D U M
V I A E - M A I L
To:
Christie Thomas, Strategic Relationship Executive, Large & National Sales
Blue Cross Blue Shield of Arizona
From:
Jeanna Carlton
Sr. Health Benefits Analyst, Client Manager
Date:
June 9, 2022
Re:
Best and Final Offer for Request for the City of Chandler
RFP #HR2-948-4453
Segal, on behalf of the City of Chandler, hereby requests a “Best and Final” offer for Medical/Rx from
your firm. The offer is an opportunity for your firm to make revisions to your cost proposal that you
feel would make your offer more attractive. If you do not submit a revised offer by the due date and
time, your previous offer will be considered your final offer.
Please note your “Best and Final” offer should include the following items:
1. Answer the attached questionnaire.
2. Completion of the attached Best and Final Financial Exhibit Spreadsheets.
Your “Best and Final” offer must be submitted via e-mail to jcarlton@segalco.com no later than 12:00
p.m. Arizona time on Wednesday, June 15, 2022.
Should you have any questions regarding the content of this request, please contact Jeanna Carlton at
jcarlton@segalco.com for assistance.
1. Confirm that you will maintain the current contract provision that you firms reserves the right to
adjust rates if enrollment varies by +/-15%?
BCBSAZ confirms.
2. Confirm that your firm will notify the City of any major operational changes, as per current practices.
BCBSAZ confirms.
3. Confirm that your firm will notify the City of any services outlined in the scope of work be
subcontracted, as per current practices.
BCBSAZ confirms.
4. Confirm that your firm will notify the City of any communications that will be released to the
employees, as per current practices.
BCBSAZ confirms.
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5. Confirm that your firm may not subcontract all or substantially all of the scope of work, without the
express written permission of the City. A subcontract does not include any contract between
BCBSAZ and any health care provider or any contract between BCBSAZ and any third party
administrator reimbursement entity or any specially contracted health care provider arrangement.
BCBSAZ confirms.
6. Confirm that your firm will maintain the termination provisions as outlined in the current contract
with the City.
BCBSAZ confirms.
7. Your firm only holds online historical claims data for 2 years, however you store claims data offline
for 7-10 years. How soon will data not stored online be available if requested by the City of the
City’s broker of record?
Once data has been moved to the data archives, it may be up to approximately three weeks to
obtain the historical data from MetaVance medical claims. This is an estimated timeframe because
we often need to work with requestors to translate their requests into the names of the data fields
that are archived.
8. The PBM agrees to notify the City or its designee in advance of 90 days when a formulary drug is
targeted to be moved to or from the preferred drug list. The PBM must provide a detailed disruption
and financial impact analysis at the same time. Please confirm.
BCBSAZ is offering our multi-tiered benefit program which applies to all our at-risk business in
addition to self-funded groups. Because a single program is used for all business, BCBSAZ is able
to negotiate better rebate arrangements with pharmaceutical manufacturers while keeping our
goal of lowest net cost. Changes requiring member notification must be made in compliance with
Department of Labor requirements, which BCBSAZ adheres to.
BCBSAZ’s Pharmacy and Therapeutics (P&T) Committee meets on a quarterly basis to review
recommended changes and make determinations for our book of business.
Any negative changes are communicated in adherence with Department of Labor (DOL)
requirements to utilizing members. Impacted members are provided a 60-day notice prior to
changes becoming effective.
A detailed reporting of impacted members could be provided to the group upon request.
9. Confirm that your firm is compliant with the No Surprises Act and the Transparency in Coverage
regulations as it relates to the following pieces of the regulations: Public Disclosure of Medical In
and Out-of-Network Machine-Readable Files, Independent Dispute Resolution, Qualifying Payment
Amount, ID Card Requirements, External Review, and Adjudication of Claims (emergency services
covered at non-participating facilities, services /items provided by non-participating provider at a
participating facility, and non-participating air ambulance services at same participant cost-sharing
as participating provider/facility, providers and facilities are banned from balance billing).
BCBSAZ confirms.
10. Confirm that your firm will provide an allowance for a dependent audit.
BCBSAZ confirms. Our proposal includes a General Fund allowance of $25,000 for the policy
period of 1/1/2023 through 12/31/2023, to be used at the City’s discretion. In addition, we have
included a $5,000 Dependent Audit allowance for the policy period 1/1/2023 through 12/31/2023.
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11. Confirm that your firm has completed in its entirety the attached Excel Pharmacy Benefit Manager
workbook.
BCBSAZ confirms.
12. Confirm that your firm has completed the attached Excel workbook for Medical Plan Administration
Fees. Complete the worksheets in their entirely accurately. Be sure to pay special attention to the
worksheet labeled Other Fees.
BCBSAZ confirms.
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Exhibit A 2
BCBSAZ Response to RFP Exhibit A and Questionnaire Parts A and B
MINIMUM CONTRACTUAL REQUIREMENTS QUESTIONNAIRE
Indicate “Yes” or “No” as to the Proposer’s ability to meet the minimum requirements. Failure to
complete this form and include it with the response may result in elimination from
consideration.
A “Yes” response shall result in the provision being adopted in the final contract. No deviations will
be accepted for “Yes” answers in this section.
MINIMUM CONTRACTUAL REQUIREMENTS
YES
NO
1. Have you proposed a single bundled package including, medical
and pharmacy claims administration, medical and pharmacy
preferred provider network, HSA administration, disease
management, and utilization review/case management for
medical and pharmacy, wellness services and stop-loss
insurance?
Yes
2. Proposal, Interview, and Best and Final Responses Become
Part of Contract: Do you agree that your written response to
this RFP, written information provided as part of an interview
and written responses provided during a Best and Final
negotiation become part of the contract between your
organization and City of Chandler?
Yes
3. Effective Date of Offer: Bid terms are guaranteed for at least
180 days from the proposal due date.
Yes
4. Your contract has a length of two (2) years with the option to
renew three (3) additional two-year periods.
Yes
5. Rates/Fees are guaranteed for a minimum of 12 months.
Yes
6. Renewal Notification: The vendor must provide any rate
changes in writing with full justification, and detailed
underwriting calculations, by June 1 of the prior plan year for a
January 1 effective date. Additionally, the vendor must provide
the following with each renewal package:
a. Any contract language changes requested
b. Specific justification of rate/fee changes
c. Current enrollment by rate class
d. Additional options for consideration
e. All underwriting caveats
a. Any proposed plan design or benefit changes
Yes
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MINIMUM CONTRACTUAL REQUIREMENTS
YES
NO
7. Variance Provision: Any provisions, references, or guidelines
relating to reevaluation of proposed fees due to variation in
enrollment in the plan must not be less than 15% of the
enrollment at the beginning of each plan year.
Yes
(see
below)
8. Do you agree that your proposal is not contingent on acceptance
of other coverages or services outside the Scope of this RFP?
Yes
9. Claims and Appeals Regulations: Do you agree that your
systems, internal operations, correspondence, and services will
be compliant with ERISA Claims and Appeals Regulations (as
applicable) and the City of Chandler’s plan document?
Yes
10. Right to Audit: The City reserves the right to an independent audit
by an auditor of their choice. Bidder agrees to not charge for any
expense incurred by the bidder for time necessary to prepare
claim files. The cost of the third party to audit will be the
responsibility of the City.
No
(see
below)
11. Prior Notice of Major Operational Changes: Do you agree to
provide no less than 30-day notice to the City of Chandler for any
changes involving the sale, merger, data breaches, layoffs,
participating provider facility terminations, consolidation or
outsourcing of services to foreign workers that will impact the
City?
No
(see
below)
12. Do you agree to maintain proper licensure as required by any
state law where it relates to the services that you will be
performing for the City?
Yes
13. Do you agree the contract will contain an indemnification
provision pursuant to which the contractor must indemnify,
defend, and hold harmless the City and its officials, agents, and
employees?
Yes
14. HIPAA Compliance: Offeror attests to meeting all applicable
HIPAA EDI, Privacy, Security, and HITECH requirements and
agrees to hold the City of Chandler harmless for breaches that
are the result of Offeror actions. As relates to the service
specified in this proposal, Offeror will become a HIPAA Business
Associate of the City of Chandler.
Yes
15. Are you willing to sign a contract with the City that indicates your
firm will pay fines the City may be assessed as a result of your
firm's noncompliance with HIPAA EDI, Privacy and Security
regulations and pay costs associated with remedy of any breach
your firm initiates?
Yes
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MINIMUM CONTRACTUAL REQUIREMENTS
YES
NO
16. Subcontracting: Unless otherwise explained in this RFP, do you
agree that you will disclose all subcontractor arrangements, and
any additional fees associated with the subcontractor
arrangements, that involve the services provided to the City of
Chandler?
No
(see
below)
a. List any services related to the Scope of Work of this RFP that
you currently subcontract (or plan to subcontract for this
contract) and the name of the vendor(s) to whom you
subcontract.
Yes
(see
below)
b. Do you agree to provide advanced written notice to the City if
you decide to subcontract for any services related to the
Scope of Work?
No
(see
below)
c. Do you understand that if you use subcontractors in the
delivery of your services under this proposal your firm is
responsible for the timeliness, accuracy, privacy,
comprehensiveness, and reporting components of the
subcontractor’s services?
Yes
d. Explain any of your current contractual relationships with a
third-party firm in which the third-party firm will be paid by
the City either directly or indirectly during the course of the
contract with the City (e.g. % of savings).
Yes
(see
below)
17. Rights to Claims Data: All member claim records are the sole
property of the City of Chandler. Selling of the City’s data to
outside entities must be disclosed and approved in writing in
advance by the City of Chandler. All claims data obtained during
the contract period and for up to seven years after the contract
termination is the property of the City of Chandler and must be
available upon request.
Yes
18. Pended Claims: Make available, upon request, reports regarding
the number and nature of claims pended, if your organization is
processing the claims.
No
19. On-Line Historical Data: Maintain at least seven years of City of
Chandler’s claims data (all fields indicated on the billing) and
eligibility information at all times.
Yes
(see
below)
20. Recoveries: 100% of all validated recoveries made through the
vendor, its subcontractors, or City audits will be credited to City
of Chandler’s experience.
No
(see
below)
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MINIMUM CONTRACTUAL REQUIREMENTS
YES
NO
21. Maintenance, Ownership, and Transfer of Records:
a) The vendor will be required to maintain all pertinent records
for seven years. This is in conjunction with prudent business
practice and (as applicable); and
b) The vendor will be charged with the safekeeping of plan
experience information; and
c) In the event of contract termination, and related to contract
termination, the vendor will be required to cooperate with
The City of Chandler, or their representative, in the prompt,
accurate, and orderly transfer of the City’s plan experience,
claims and utilization information to the City or its designated
succeeding carrier at no added fee.
Yes
(see
below)
22. Confirm you will handle all levels of claim appeals, including (as
applicable) External Reviews.
Yes
23. Eligibility Rules and Uncertain Claimant Eligibility Situations:
The Offeror agrees to the specified eligibility rules established by
the City of Chandler. The vendor(s) must communicate directly
with the City regarding any uncertain claimant eligibility
situations before notifying the claimant of ineligibility.
Yes
24. Eligibility Rules and Procedures for Retroactive Termination
and Reconciliation: The vendor agrees to the specified eligibility
rules established by the City of Chandler. Upon receipt of a
retroactive termination, the vendor must review the applicable
patient histories and initiate recovery efforts for any
overpayments resulting from the late termination notice.
Yes
(see
below)
25. If requested by the City, Contractors must conduct a full
dependent audit at no additional charge to the City. Will you
agree to this request?
No
(see
below)
26. No Member Communication Without the City’s Consent: The
Offeror will not automatically enroll the City of Chandler in any
programs that involve any type of communication with
members, without express written consent from the City?
No
(see
below)
27. Termination Provisions: The City of Chandler may terminate
the contract at any time after the first complete plan year
without cause, by giving 30 days written notice. The City can
terminate with cause with 30-day notice unless proper remedy is
provided by the Offeror.
No
(see
below)
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MINIMUM CONTRACTUAL REQUIREMENTS
YES
NO
28. Claim Run Out: Do you agree to process run out claims for 12
months after the termination date for claims incurred during the
policy period at no additional cost to the City?
Yes
29. Assignment or Transfer of Rights: Do you agree that you will
not assign or transfer the rights or obligations of the contract or
any portion thereof, without the prior written approval of the
City of Chandler?
No
(see
below)
30. The successful vendor's proposal must contain provisions
reserving these rights to The City of Chandler:
No-Loss, No-Gain & Waiver of Actively-at-Work: Current
participants in any of the City’s sponsored health care plans will
be provided coverage on a "no-loss, no-gain" basis. Any “actively-
at-work” or non-confinement requirements will be waived on the
effective date for all members or dependents participating in the
plan immediately prior to the effective date of your contract with
the City.
Yes
31. Implementation and Communications Allowances: Confirm you
agree to provide the following allowances to the City upon
execution of a contract to offset the Plan costs:
a. $25,000 Implementation and Communications Allowance
See
commen
t below
32. Audit Allowance: Confirm you agree to provide an audit
allowance of at least $25,000 for the City to use at their
discretion anytime during the contract period.
See
commen
t below
33. Wellness and Misc. Trust Allowances: Confirm you agree to
provide the following annual allowances to the City upon
execution of a contract to offset the Plan costs (any unused
funds at the end of the year could be rolled over to the next
year):
a. $80,000 miscellaneous Trust and Wellness allowance
Yes
b. $100,000 Wellness Coordinator allowance
Yes
34. Commissions:
a) Is your proposal submitted net of commissions?
Yes
b) If commissions are built into your rates, and cannot be
stripped out, will you pay them to the City’s consultant, Segal?
N/A
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If you answered “No” to any of the questions above, please provide an explanation below:
Requirement No.
Explanation
7. Variance
Provision
Blue Cross® Blue Shield® of Arizona (BCBSAZ) reserves the right to
adjust these premium rates retroactive to the first day of any billing
month in which enrollment varies by more than 10 percent from
that listed in the BCBSAZ Rates and Assumptions in Section 2B.
Additionally, the following assumptions are included in our proposal:
•
Rates assume BCBSAZ is the sole medical and pharmacy (if
applicable) carrier.
•
Where the employer contributes 100 percent of the employee
cost, BCBSAZ requires 100 percent participation.
•
Where the employer does not contribute 100 percent, BCBSAZ
requires 70 percent of all eligible employees to participate.
•
BCBSAZ requires a minimum of 50 percent of all full-time
eligible employees in the group to be enrolled in the
employer's group plan.
•
Employer must contribute a minimum of 50 percent of the
employee's health premium.
•
Payroll deduction for employee contribution is required.
•
BCBSAZ reserves the right to re-evaluate and change the rates
if the client adds or deletes a benefit-eligible class that will have
BCBSAZ medical coverage.
•
Healthcare reform proposals include provisions for increases
on fees and taxes paid by insurance companies which may
result in an increase in your rate.
If the government imposes a new tax or fee on insurers, the rate set
forth in this rate proposal may be adjusted.
10. Right to Audit
Audits are subject to the BCBSAZ audit requirements noted in
Section 5S.
If either BCBSAZ or the City desires to utilize an outside auditing firm
to perform the audit, both BCBSAZ and the City must agree on the
selection of the outside auditing firm. BCBSAZ will only approve
auditors that are independent and objective and will not approve
auditors paid on a contingency fee or other similar basis. The party
requesting the audit will be responsible for the audit fees charged by
the auditing firm. BCBSAZ agrees to support audit activity without
charging the client for the time supporting the audit activity.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
11. Prior Notice of
Major Operational
Changes
No. As the Covered Entity, BCBSAZ agrees to provide breach
notifications to impacted members as required by the Health
Insurance Portability and Accountability Act (HIPAA) and the Health
Information Technology for Economic and Clinical Health Act
(HITECH), and any other applicable regulations. Such notifications
shall follow deadline and content requirements as stated under
these regulations.
Additionally, employer groups generally are not notified when
providers terminate, but on an exception basis, when a large
provider group or hospital terminates, BCBSAZ may send
notification. Our provider directory is updated every weekday, with
the exception of holidays, to reflect changes in the network.
Contractor cannot agree to obtain the City of Chandler (the City)
prior approval for all subcontracting but does agree not to
subcontract all, or substantially all, of the scope of work under this
Agreement without the City’s express written consent.
16.
Subcontracting
BCBSAZ is unable to agree to the City’s request because as a hospital
medical service corporation we have significant contracts with a
wide range of providers, including healthcare providers, third party
administrator reimbursement entities and specialty contracted
healthcare provider arrangements. In addition, BCBSAZ has normal
service arrangements with information systems providers such as
Microsoft.
“Subcontractor” does not include any contract between BCBSAZ and
any healthcare or specialty contracted healthcare provider
arrangement and shall not include any normal service arrangements
with information systems providers (e.g., Microsoft).
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16a
BCBSAZ subcontracts with the following for services for the City:
• OptumRx®, provides certain pharmacy services, including
claims processing, customer service, network audit, network
management (mail order and the exclusive specialty pharmacy
benefit management).
• HealthEquity, Inc. provides flexible spending account (FSA),
health reimbursement account (HRA) and health savings
account (HSA) administration and banking services.
• Sharecare provides certain disease management, wellness,
and online health services.
• HealthSparq provides access to provider directory by network,
along with cost estimates for procedures and ability to rate
providers’ services.
• American Specialty Health (ASH) Incorporated provides the
chiropractor network.
• Amwell provides telehealth services for urgent care,
counseling, and psychiatry.
A full list of BCBSAZ subcontractors is provided in Section 5T.
16b
BCBSAZ is unable to agree to the City’s request because as a hospital
medical service corporation we have significant contracts with a
wide range of providers, including healthcare providers, third party
administrator reimbursement entities and specialty contracted
healthcare provider arrangements. In addition, BCBSAZ has normal
service arrangements with information systems providers such as
Microsoft.
“Subcontractor” does not include any contract between BCBSAZ and
any healthcare or specialty contracted healthcare provider
arrangement and shall not include any normal service arrangements
with information systems providers (e.g., Microsoft).
16d
BCBSAZ pays service fees to all of the vendors noted as
subcontractors in the included subcontractor list. The fees are
included in our proposed offer.
18
This may be discussed during implementation. BCBSAZ would need
further clarification regarding the City’s definition of pended claims
and the expected frequency of the pended claims report. Once this
detail is determined, we can provide a mutually agreed upon report
based on the City’s needs.
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19
BCBSAZ uses imaging for maintaining claims documents. For
security and disaster recovery purposes, records are maintained at
our headquarters building and two additional locations.
BCBSAZ maintains a minimum of two years (24 months) claims
history online. Claims history is stored offline for seven to 10 years
(84 to 120 months), depending on the applicable retention
requirement.
20
Overpayment recovery charges are passed on to the group; BCBSAZ
will return recovered amounts to the group, net of amounts retained
by the subcontracted vendor(s). BCBSAZ does not retain any
compensation for overpayment recoveries; all monies recovered are
returned to the group, less the fee retained by the subcontracted
vendor.
BCBSAZ or our outside vendor may not be able to recover the
overpayment due to the following situations:
•
BCBSAZ does not pursue collection of amounts less than $35
•
Some of our provider contracts limit the amount of time we
have to collect claims paid after termination
•
Arizona Revised Statutes (ARS) prevent us from recovering
erroneously paid claims more than one year from the date paid
•
Bankruptcy regulations prevent us from recovering
erroneously paid claims from someone who has filed
bankruptcy
•
Similar provisions may apply to claims administered via the
national BlueCard® program
As noted above, when permissible, BCBSAZ or our outside vendors
attempt to recover overpayments.
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21
BCBSAZ uses imaging for maintaining claims documents. For
security and disaster recovery purposes, records are maintained at
our headquarters building and two additional locations.
BCBSAZ maintains a minimum of two years (24 months) claims
history online. Claims history is stored offline for seven to 10 years
(84 to 120 months), depending on the applicable retention
requirement.
BCBSAZ shall establish and maintain a record-keeping system
relating to the services performed under this Agreement. Upon
reasonable prior notice, such records shall be available for
inspection by the employer at any time during BCBSAZ's normal
business hours at BCBSAZ's principal place of business or other
address(es) designated by BCBSAZ. Upon reimbursement by the
employer for expenses of copies and labor, any copies requested
shall be delivered to the employer within six months of termination
of this Agreement. BCBSAZ reserves the right to retain copies of all
or any of such records as it deems appropriate.
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24
BCBSAZ will return any overpayments collected from successful
recovery attempts to the City. Please note that not all recovery
attempts are successful.
If the overpayment amount is $35 or more, BCBSAZ will:
1. Send a series of letters to the recipient requesting return of the
overpayment
2. If possible, offset the amount against future payments
3. Refer uncollected debts to an outside collection agency
4. Involve our special investigations unit if it appears that
potential fraudulent activity occurred
5. Credit the account with the funds collected net of any collection
agency fees
Diagnosis-Related Group (DRG) and Hospital Bill Audit
BCBSAZ subcontracts with Change Healthcare to perform DRG and
hospital bill audits. Change Healthcare identifies which claims to
audit and requests medical records from the provider. Discrepancies
in billing are validated with the provider and recoveries are initiated
by Change Healthcare on any overpayments identified. Change
Healthcare’s recovery fee is 21.5 percent of the savings identified
and collected.
Collection Agency Efforts
BCBSAZ subcontracts with Vengroff, Williams & Associates, Inc. to
perform elevated overpayment recovery. Elevated overpayment
recovery occurs when BCBSAZ and/or Change Healthcare are unable
to collect the debt. The recovery fees are 25 percent on the first
$2,000 or less, and 20 percent on amounts in excess of $2,000
collected per claim.
Monies Returned to the Group
Overpayment recovery charges are passed on to the group; BCBSAZ
will return recovered amounts to the group, net of amounts retained
by the subcontracted vendor(s). BCBSAZ does not retain any
compensation for overpayment recoveries; all monies recovered are
returned to the group, less the fee retained by the subcontracted
vendor.
BCBSAZ or our outside vendor may not be able to recover the
overpayment due to the following situations:
•
BCBSAZ does not pursue collection of amounts less than $35
•
Some of our provider contracts limit the amount of time we
have to collect claims paid after termination
•
Arizona Revised Statutes (ARS) prevent us from recovering
erroneously paid claims more than one year from the date paid
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
•
Bankruptcy regulations prevent us from recovering
erroneously paid claims from someone who has filed
bankruptcy
•
Similar provisions may apply to claims administered via the
national BlueCard® program
As noted above, when permissible, BCBSAZ or our outside vendors
attempt to recover overpayments.
25
If either BCBSAZ or the City desires to utilize an outside auditing firm
to perform the audit, both BCBSAZ and the City must agree on the
selection of the outside auditing firm. BCBSAZ will only approve
auditors that are independent and objective and will not approve
auditors paid on a contingency fee or other similar basis. The party
requesting the audit will be responsible for the audit fees charged by
the auditing firm. BCBSAZ agrees to support audit activity without
charging the client for the time supporting the audit activity.
Audits are subject to the BCBSAZ audit requirements noted in
Section 5T.
26
Some BCBSAZ programs and events will trigger an immediate
member phone call. This includes:
•
Certain enrollment needs
•
Health coaching outreach
Disease management (DM) outreach (conducted based on triggers,
including results of the health risk assessment, medical and
pharmacy claims data, etc.).
27
Termination Provisions: The City of Chandler may terminate the
contract at any time after the first complete plan year without cause,
by giving 90 days written notice. The City can terminate with cause
with 30 day notice unless proper remedy is provided by the vendor.
The vendor may only terminate for cause with proper legal
minimum notice requirements.
Vendor may terminate the Contract effective immediately in the
event of a material breach of the Agreement by the City, but only if
the breach is not cured within thirty (30) days after written notice of
the breach is given to the City. Additionally, Vendor may terminate
the Contract in the event of a material breach by the City under any
other agreement with Contract which remains uncured for the
applicable cure period reflected in such other Agreement.
Notwithstanding Paragraph above, Vendor may terminate the
Contract upon five (5) days’ prior written notice to the City if the City
fails to provide funds necessary to satisfy its liability for payments
for Covered Services.
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29
BCBSAZ cannot agree to obtain the City’s prior approval for all
subcontracting, but does agree not to subcontract all, or
substantially all, of the scope of work under this Agreement without
the City’s express written consent.
31 and 32
BCBSAZ is offering one $25,000 general fund to be used at the
discretion of the City for audits/implementation/communication.
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
1. Identify those individuals who would be
responsible for the day-to-day service contact for
the City.
BCBSAZ will continue to provide a
framework of employer support to meet
and exceed our clients’ implementation,
pre-open enrollment, open enrollment, and
ongoing needs. The City of Chandler’s (the
City’s) team will include:
Christie Thomas, Strategic Relationship
Executive (SRE)—Christie maintains overall
responsibility for the BCBSAZ account
management team, acting in a consultative
and collaborative role. Additionally, she
assists with the creation and execution of
multi-year strategic plans to help you
achieve your long-term goals.
Rita Reyes, Client Service Manager
(CSM)—Your CSM, Rita, manages all service
aspects of your account by working with
your staff to facilitate plan activities and
address detailed service needs. This
includes support for group enrollment and
ongoing employee benefit meetings and
elevated claim inquiries.
Eric Johnson, Client Implementation
Manager (CIM)—Your CIM, Eric, serves as
your main contact during implementation
and manages the internal BCBSAZ
implementation team to ensure a seamless
transition.
Jessica Dunn, Health Promotion
Executive (HPE)—Jessica, provides wellness
consultation and acts as the subject matter
expert in the development, implementation,
and evaluation of worksite wellness
programming. Her primary role is to create
an individualized, comprehensive strategy
designed to engage employees and meet
the City’s wellness goals and objectives.
2. If your company is awarded this business, how
soon after notification of the award would you be
able to have a draft of the:
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
a. Benefits Summaries/SBCs?
For incumbent groups, BCBSAZ provides
SBCs in approximately seven business days,
once benefits have been finalized. Upon
award your dedicated implementation team
will hold an initial meeting with the City to
review enrollment, obtain any necessary
information.
b. Plan booklets?
The certificate (benefit) book can be drafted
60 days after benefit finalization.
3. All sample forms and communication materials
should be provided for approval to the City in
advance of distribution (ID cards, claim forms,
enrollment forms, booklets, brochures, flyers,
mailers, etc.). Do you agree to this requirement?
Yes. BCBSAZ will provide sample materials
in advance of distribution.
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
4. Does your firm have the capability to provide
communication pieces in Spanish and other
languages? Please specify.
Yes. BCBSAZ will provide summaries of
benefits coverage (SBCs) and benefit
booklets to the City in Spanish in
accordance with applicable state and
federal laws and healthcare requirements.
In addition, many health and wellness
materials are available in Spanish.
Yes, when members call BCBSAZ’s customer
service number there is an option to listen
to choices in Spanish and speak with a
representative in Spanish.
In addition, we work with LanguageLine
SolutionsSM to communicate with members
in more than 200 languages, including the
most prevalent languages spoken in the
United States. Our telecommunications
translator service currently accommodates
50 specific language requests.
The languages supported are: Albanian,
Amharic, Arabic, Armenian, Bengali,
Bosnian, Bulgarian, Cambodian, Cantonese,
Creole, Croatian, Czech, Egyptian (Arabic),
Ethiopian (dialect), French, German, Greek,
Gujarati, Haitian Creole, Hebrew, Hindi,
Hmong, Hungarian, Indic, Indonesian,
Italian, Japanese, Korean, Laotian,
Malayalam, Mandarin, Persian (Farsi/Dari),
Polish, Portuguese, Punjabi, Romanian,
Russian, Serbian, Serbo-Croatian, Slovenian,
Somali, Spanish, Tagalog, Taiwanese, Tamil,
Thai, Turkish, Urdu, Vietnamese, and
Yugoslavian.
5. What are the most recent ratings for your
company by the following:
Rating
Date
Standard and Poor’s
BCBSAZ is not publicly rated. We do,
however, comply with the significant
liquidity and capital requirements of the
Duff and Phelps
A.M. Best
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
Moody’s
BCBSA and meet the Arizona Department of
Insurance and Financial Institutions (DIFI)
risk-based capital standards.
In addition, Weiss Ratings (formerly
TheStreet.com Ratings, Inc.) reviews our
annual health statement as filed with the
Arizona DIFI and the National Association of
Insurance Commissioners (NAIC). BCBSAZ
has consistently received an A+ rating every
year since 2003.
6. Is your company "affiliated" with another
company? If so, describe the "affiliate
relationship." "Affiliated" means owned by
another company, owned by a common
controlling shareholder or interest, or inter-tied
by contract so as to be under the dominion or
influence of another.
No. BCBSAZ is an independent licensee of
the BCBSA and not affiliated with another
organization.
7. If your firm is not a corporation, please advise
who each of the partners, proprietors or other
owners are and whether they have interest in any
Employee Benefits services provider firms.
Not applicable. BCBSAZ is a not-for-profit
corporation.
8. Is your firm involved in any current litigation
against or from the City? If yes, please describe.
No.
9. Have you been involved in litigation within the
last five years arising out of your performance in
the administration of a benefit plan? Exclude
routine matters involving participants that do not
reflect on your performance under the contract
with your Client. If the answer is yes, explain fully.
Yes. BCBSAZ is involved in certain litigation
regarding benefits. While it is not possible to
predict the outcomes of litigation based on
the status of the existing lawsuits, we do not
believe the current lawsuits will have a
material adverse effect on the company.
10. Do you anticipate any restructuring or
reorganizing in the next two years? (Include any
major staff relocations or office closings.)
No. Our employees reside in the state of
Arizona with the majority of our employees
living in the Phoenix Metropolitan area.
BCBSAZ has no plans to reorganize or
restructure in a manner that would cause
staff relocations or office closures. We are
currently reorganizing the way we work by
aligning dedicated business segments and
support operations to the customers we
serve. The structure will get us closer to our
customer and provide enhanced member
services and offerings.
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
11. Do you understand that you are prohibited from
using the IIHI for any purpose other than as
required by law and further agree to promptly
destroy such data if you are NOT the successful
bidder?
Yes. BCBSAZ agrees to secure or destroy
such data in a secure and compliant
manner as directed by both HIPAA and
HITECH Federal Legislation.
12. What is the minimum amount of implementation
lead-time needed to initiate the proposed
services?
BCBSAZ would prefer at least 90 days’ lead
time for installation and 30 days for set up
(total of 120 days). We have developed a
proposed implementation plan for your
consideration and input. If selected as your
new benefits provider, we will meet with
you to customize this implementation plan.
Please see Section 5U for the proposed
implementation timeline.
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13. List any transition issues the City should consider.
BCBSAZ is the City’s incumbent carrier and
as such, transition issues will be minimal.
Your BCBSAZ CIM, Eric Johnson, will work to
ensure a smooth transition for your group
benefits administrator (GBA), your
employees and their families. BCBSAZ is
committed to providing the City with a
seamless implementation transition. Your
dedicated team is experienced in
successfully implementing large groups
quickly and effectively without
compromising continuity of care and service
to our members.
BCBSAZ has an extensive provider network;
therefore, transition from another health
plan to BCBSAZ for services such as ongoing
chemotherapy treatments or scheduled
surgeries is not usually an issue. The
BCBSAZ Sales and Utilization Management
(UM) Departments will work closely with the
GBA and member as transition of care
needs are identified. Prior authorization can
be arranged in advance of the contract
effective date so that care is not disrupted.
In the event a member’s current provider is
not contracted with BCBSAZ, every effort
will be made to ease the transition to
BCBSAZ. Depending on the individual
situation, a special contract may be
negotiated with the non-contracted
provider for BCBSAZ to continue to provide
access to care for the affected member.
Assistance locating an in-network provider
qualified to handle their specific needs is
also provided.
Members who are in the last trimester of
pregnancy can choose to have their
obstetricians notify our UM Department to
arrange necessary pre-certifications for
claims to process at in-network benefit
levels. The BCBSAZ network contract
specialist contacts the obstetrician
regarding a letter of agreement to accept
BCBSAZ rates. Our registered nurse (RN)
case managers are also available to assist in
any transition of care needs.
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
New members who may require additional
coordination of care as they transition to
the BCBSAZ plan and network can be
referred to our care management program.
14. List any specific administrative procedures or
information your firm will need from the City in
order to implement your services?
When BCBSAZ is selected, our dedicated
implementation team will hold an initial
meeting with the City to review enrollment,
obtain any necessary information, provide
materials, and discuss how to best engage
the City’s employees and their families.
BCBSAZ has listed all segments of the
implementation in the timeline. Please refer
to the implementation timeline in Section
5U for specific details.
15. Do you agree to provide the City a clear path
(representative phone number or email, etc.) for
employees to register complaints?
Yes, BCBSAZ agrees.
Your CSM, Eric Johnson, will serve as the
day-to- day contact and provide support for
issue resolution.
16. Identify any services under any subsequent
contract that may be awarded as part of this RFP
that are currently or planned to be performed
outside the borders of the United States.
BCBSAZ does not anticipate outsourcing of
our member-facing services offshore to
foreign workers. Member-facing processes
(i.e., customer service, sales support, and
broker services) are performed locally at our
offices in Arizona.
BCBSAZ support may include technological
and back-office operations and other
limited claims work with overseas vendors.
Some initial claims reviews and
precertification services for providers are
performed outside the U.S.
Offshore support does have access to PHI.
PHI is not stored offshore for these
functions. All data is stored onshore in
BCBSAZ's systems. Access is through a
virtual desktop interface application.
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1. GENERAL INFORMATION (ALL PROPOSERS)
VENDOR RESPONSE
17. What additional services or enhancements to the
current service offerings is your firm willing to
provide?
BCBSAZ is offering our Alliance network, to
assist the City in lowering costs and
improving care. Alliance is an accountable
care organization (ACO)-based exclusive
network serving the metro Phoenix area. It
is anchored by two well-established ACOs:
Banner Health Network ACO and
HonorHealth Innovation Care Partners ACO.
The network includes all hospitals, facilities,
and providers affiliated with these ACOs in
Maricopa County and in some parts of Pinal
County. This network is based on lowering
costs and improving care for the
members/employer groups who choose this
network offering. As part of the
collaboration, there is a shared savings
component that incentivizes for the efficient
delivery of care. For self-funded clients,
there is a $2 per member per month care
coordination fee that applies.
Please see Section 4R for our Alliance
Exclusive Network flyer.
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1.
GENERAL INFORMATION (ALL PROPOSERS)
FEDERAL NO SURPRISES ACT AND
FINAL TRANSPARENCY RULE
VENDOR RESPONSE
1. Describe how your company will assure that the
Plan will be in compliance with federal law and
regulations concerning surprise billing and
transparency with respect to the services
provided by your company.
BCBSAZ currently has multiple efforts
underway to drive compliance with the new
surprise billing and transparency legislation.
We expect to be fully compliant with all
elements of the legislation by the associated
compliance or enforcement dates (as
appropriate for each initiative.)
2. List any subcontractors or third-parties who are
providing assistance to you in complying with the
law and regulations, or who will be involved in
work you may perform on behalf of the Plan.
We are leveraging services from
HealthSparq® in the generation and
distribution of our machine-readable files
under the transparency act.
3. List any technical specifications that the Plan will
need to meet in order to use any solution you
intend to offer to comply with the law and
regulations, including software, hardware, or
other information technology.
Technical specifications required are still
under development. We will communicate
any technical specifications in the second
quarter of 2022, as our MRFs are available.
4. Do you expect to be fully compliant with the law
and regulations by the statutory and regulatory
due dates? If not please explain.
Yes
5. Are the fees you propose inclusive of all services
related to the law and regulations? If not, please
explain what additional costs the Plan may incur.
Yes
TRANSPARENCY RULES
VENDOR RESPONSE
1. Describe your general process for complying with
the Transparency in Coverage Final Rule.
We are working with HealthSparq® to make
our machine-readable files available via web
access, as mandated by the legislation. Our
processes include provisions for monthly
updates to maintain currency of the
information.
2. Will you prepare an internet-based self-service
tool that makes available to plan participants real
time cost-sharing information in accordance with
the rule?
Yes
a. Do you currently offer an internet-based self-
service tool? If so, please describe how it
differs from the regulations and how you will
revise it.
We currently use a tool developed by our
partner HealthSparq to provide cost
information. It currently does not contain
information on all services required under
the legislation, and we are working with
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HealthSparq to expand the services
included.
b. Please provide screenshots of the web portal
to be used for the participant cost-sharing
disclosure.
Please see Section 5V Transparency Rules -
Participant Portal Screenshots.
c. How will you make the tool available to plan
participants, through your website, by
providing information to plans, or through
another option?
Access will be through the secure member
portal.
d. How will the required participant notice of
disclosure be provided?
This service is still being finalized.
e. How will you respond to individuals who
request the information on paper instead of
through the website?
This capability is still in development.
3. Will you provide the City with any of the three
machine readable files on a monthly basis
including in-network rates, out-of-network
allowed amounts, and prescription drug
negotiated rates? If so, describe which files will
be provided.
Yes, all three machine-readable files will be
available via the web for access by plans. The
information will be updated monthly.
a. Describe the information technology
requirements necessary for transmitting files
and/or posting them.
This capability is still being finalized.
b. If the City uses multiple service providers for
in-network or out-of-network pricing, will you
provide assistance in consolidating the
information into one file?
This is not applicable with our scope of
services. BCBSAZ will provide MRFs for those
providers that are under claims
administered by BCBSAZ.
c. Will you send information to the City or
provide another service to the City that allows
the City to link you and another website?
Details are still being finalized, but BCBSAZ
anticipates directing plans to the preferred
vendor website for obtaining the MRFs.
GAG CLAUSE
VENDOR RESPONSE
1. Do any contracts you are a party to contain a
claim prohibiting disclosure of pricing terms (“gag
clause”) which will be prohibited under the No
Surprises Act?
BCBSAZ believes that current contracts do
not have any language that would prohibit
disclosures protected under federal law. In
an abundance of caution, we will amend all
provider contracts before year-end to mirror
requirements in the federal law.
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a. If yes, please describe and state how you will
assure they are removed. Indicate your
timeline for removing gag clauses from
contracts.
BCBSAZ anticipates this project will be
completed on or before January 1, 2022.
NO SURPRISES ACT
VENDOR RESPONSE
1. Describe your process for paying for Emergency
Services, Non-Emergency Services provided at an
In-Network Facility, and Air Ambulance Services
(“Covered Services”) under the No Surprises Act.
For claims in scope for the NSA, BCBSAZ will
send the initial payment to the provider and
will include contact information.
a. Are there any subcontractors used in
determining the amount to pay for Covered
Services? If so, please name them and
describe the services being provided.
No. BCBSAZ, or the Blue Plan in whose area
the service is provided, will determine the
recognized amount or qualifying payment
amount and BCBSAZ will calculate the
participant cost sharing.
b. Will you establish the Qualifying Payment
Amount, Recognized Amount, and Out-of-
Network Rates for the Covered Services?
Please describe your process for setting these
rates and assuring participant cost-sharing is
based on them.
Yes. BCBSAZ, or the Blue Plan in whose area
the service is provided, will establish these
rates. To the extent that a provider
challenges the initial payment amount,
BCBSAZ will negotiate that amount with the
provider up to and including arbitration, to
reach the OON rate. BCBSAZ will calculate
participant cost-sharing in accordance with
the requirements of the NSA.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NO SURPRISES ACT
VENDOR RESPONSE
2. If you are providing any preferred Network
providers, describe how PPO contracts will be
revised and what communications you will make
to those providers concerning the Act.
BCBSAZ is sending a participation agreement
amendment to all its network providers to add
the NSA language relating to no gag clauses. In
compliance with URAC accreditation standards,
we currently have similar language in our
provider contracts, but we will be updating it
with all the NSA details. The amendment will be
sent to providers in October and the process
will be completed by early December. In
addition to the contract amendment, we are
updating our Provider Operating Guide, an
extension of the provider participation
agreement, with policies and procedures
related to the NSA. These include revised
requirements for provider demographic
updates and continuity-of-care benefits. We are
in the process of updating our ID card
templates in compliance with NSA
requirements and samples of these will be
added to the 2022 Provider Operating Guide.
We also are implementing procedures to create
online functionality for receipt of provider
billing estimates and advance EOBs. We cannot
finalize those operational changes until we
receive further federal guidance and rules,
which federal regulators have indicated will not
occur until 2022. We will communicate this to
providers in advance of our go-live date.
a. Describe any provider or facility billing
processes and how they will be affected by
the No Surprises Act.
BCBSAZ is updating our Provider Operating
Guide, an extension of the provider
participation agreement, with information
about the NSA and the process for determining
and disputing the amount of reimbursement
for out-of-network (OON) services that are in-
scope for NSA balance billing protections. For
plan and policy years starting on and after
January 1, 2022 (and on 2022 renewal dates for
existing clients), we will follow the requirements
of the NSA in reimbursing OON providers for
emergency, air ambulance, and other
professional services that are in scope for the
NSA. In most cases, the initial payment to the
provider will also be based on the lesser of
billed charges or the qualifying payment
amount (QPA), minus the member cost-share
amount. Providers have the right to dispute the
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
initial payment amount. If the provider disputes
the amount, the parties attempt to negotiate
resolution. If the parties cannot agree, the
dispute is referred to an independent federal
arbitrator.
3. Are there any State laws that affect your
determination of the Recognized Amount for this
Plan? If so, please describe.
The Arizona State law will not affect the
determination of the recognized amount or the
initial payment to the provider. In Arizona, the
recognized amount will be equal to the lesser of
billed charges or the qualifying payment
amount. The Blue Plans, in whose service area
any out of state services are provided, will
determine the recognized amount, taking into
consideration state laws that apply to their
service areas.
4. How will you determine whether the patient
consented to services from an out-of-network
provider at an In-Network facility, and is therefore
not reimbursed under the No Surprises Act?
The provider is required to provide a copy of
the signed Notice and Consent to BCBSAZ. In
the absence of a signed Notice and Consent
form, claims in scope for the NSA will be
processed in accordance with the Act.
5. What support will you provide to the City if a
health care provider or facility elects to negotiate
an out-of-network payment amount or elects to
conduct Independent Dispute Resolution (IDR)?
The provider is required to provide a copy of
the signed Notice and Consent to BCBSAZ. In
the absence of a signed Notice and Consent
form, claims in scope for the NSA will be
processed in accordance with the Act.
a. Will you prepare the IDR submission on behalf
of the City at no additional cost?
BCBSAZ will support and coordinate
negotiations and IDR on behalf of our self-
insured plans.
b. Will you pay IDR fees on behalf of the City,
including general assessments and fees if the
City is unsuccessful?
Yes.
c. Will the IDR submission be approved by the
City or will the process be delegated to your
company?
Yes. The self-insured plan will be responsible
for the additional payment to the provider if a
new reimbursement is determined for the
service. Please refer to the answer above.
6. How will you assist the City to pay for IDR,
including the general assessment and specific
charges for individual IDRs?
It is the expectation that BCBSAZ will handle the
payment and charge it back to the group.
7. Will you assist the City in providing a complaint
process for plan participants who have a
complaint about bills under the No Surprises Act?
Yes. There is a federal complaint process and
BCBSAZ will assist the member as needed.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
8. Describe how the No Surprises Act will affect
payment of Air Ambulance services under the
Plan, and whether you will propose plan changes
to this benefit?
Under the NSA, BCBSAZ will make payments
directly to a non-contracted air ambulance
provider, taking into consideration the
qualifying payment amount and the
participant’s cost share. The participant’s cost
share will be calculated at INN level of benefit
utilizing the qualifying payment amount.
BCBSAZ does not propose changes to this
benefit.
9. The Act requires ID cards to contain information
about deductibles and out-of-pocket maximums.
Confirm that your provided ID cards will be in
compliance with the new regulations.
BCBSAZ has already developed compliant ID
cards. New ID cards, reflecting these changes,
will be issued upon renewal starting January 1,
2022.
10. The City’s plans are non-grandfathered. Describe
how you will support the additional External
Appeals requirements for Covered Services. Do
you provide a contract with an Independent
Review Organization for external review?
BCBSAZ’s appeals process complies with state
and federal laws and accreditation standards.
Members can file appeals, or their treating
providers can file appeals on their behalf. The
appeals process applies to adverse benefits
determinations for services not yet provided
and adverse benefit determinations of claims
for services already provided. Members have
either one or two internal levels of appeal
depending on the product, and one external
level of appeal. The external level of appeal is
performed by an IRO for self-funded clients, or
by the Arizona Department of Insurance and
Financial Institutions (DIFI) for fully insured
clients.
The time frames and process may vary with
pre-service and post-service appeals,
depending on the type of plan. Turnaround
times may be altered to meet the needs of self-
funded groups.
Enrollees and practitioners are notified of
appeal rights and the appeals process in writing
through various channels (e.g., benefit booklet,
Internet, BCBSAZ’s Provider Operations Guide
and healthcare appeals packet), and with each
claim or prior authorization of an adverse
determination.
BCBSAZ’s EOB statement also contains specific
information on our appeal process.
BCBSAZ conducts the first one or two levels of
appeals in-house; however, members may
request an IRO review for any level. BCBSAZ
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
contracts with four (4) URAC-accredited IROs,
and coordination may include level one same
specialty peer review. BCBSAZ sends the appeal
to an IRO for the external review process, using
either the grandfathered or non-grandfathered
Affordable Care Act-compliant process or if the
case is governed under the Arizona DIFI, the
case is sent to the Arizona DIFI for external
review.
NOTE: BCBSAZ includes IRO fees in our
administrative fees.
11. Describe how you will provide plan participants
with an Advanced Explanation of Benefits as
required under ERISA Section 716(f); PHSA
Section 2799A-1(f).
The details on the advanced EOBs are still being
evaluated as final rulemaking is still in
development.
a.
What process will be used to accept provider
notification of expected charges and
services?
Please refer to our response above.
b.
Describe how you will provide the Advanced
EOB to participants, i.e., via electronic
means or mail as requested by the
participant.
Please refer to our response above.
c.
Describe how you will provide reports
assuring that the Advanced EOB process is
performing as required by law.
Please refer to our response above.
12. If you provide a preferred provider network,
describe how you will implement the required to
allow continuation of care for individuals when
their health care provider is terminated from the
Network, under ERISA Section 718 and PHSA
Section 2799A-3.
BCBSAZ will notify its members that a provider
from whom they have had services is
terminated from the network. The notification
also will include information that they may have
continuing care rights and to contact BCBSAZ. If
the individual does have continuing care rights,
BCBSAZ will continue to process in-scope claims
at INN level of benefits, and the provider will
continue to accept the BCBSAZ contracted rate,
for up to ninety days.
a. What process will be used to accept provider
notification of expected charges and
services?
BCBSAZ will provide the required notice of the
law's protections on azblue.com and on the
member health statements.
13. Will you provide a price comparison tool via
internet websites and via telephone that allow a
participant to compare the amount of cost
Yes. The cost comparison tool previously
discussed will provide this functionality.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
sharing that they will be responsible for by
participating provider and geographic region?
a.
Describe the price comparison tool in detail,
and whether any subcontractors are used to
produce it.
This capability is still being finalized.
b.
Describe who will provide the telephone tool
and at what location?
This service is still being finalized.
c.
Is there a dedicated team for the City’s
participants to provide the tool and assist
with its use?
This service is still being finalized.
d.
What internet website will be used for the
price comparison tool, and will the Plan
need to provide its own website to link to
the tool or will your company provide that
site?
This capability is still being finalized.
NO SURPRISES ACT
VENDOR RESPONSE
14. Describe your process for addressing participant
or provider complaints that may be made against
the plan under the Act.
BCBSAZ anticipates utilizing our standard
appeals and grievance policy and procedures.
15. Do you provide the plan’s external review
services? If so, how will you incorporate
emergency services and air ambulance services
into the external review process?
BCBSAZ does provide the full appeals process
including, the external review level of appeal.
BCBSAZ does use four URAC-accredited
independent review organizations (IROs) for
self-funded external reviews. The services
identified will be treated like other services. If
BCBSAZ denies the claim within the initial 30-
day payment period, the member will have the
right to dispute the adverse benefit
determination.
16. Do you provide prescription drug benefits? If so,
how will you assist the plan in reporting
prescription drug costs and other information to
the federal government effective December 27,
2021?
BCBSAZ will assist plans in meeting their
reporting requirement when our integrated
PBM is used. Final rules on the prescription
reporting are still being determined.
a.
Describe your process for reporting
prescription drug cost information to the
federal government.
Details are still being finalized pending final
rulemaking.
b.
Describe whether you will accept
responsibility for fulfilling all cost reporting
Details are still being finalized pending final
rulemaking.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
obligations and if not which ones you will
not fulfill.
c.
State any additional costs for this reporting
service.
Not available at this time.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
1. Will there be a designated team of customer
service representatives for the Client?
Yes
2. Will you provide a toll-free customer service
number for claim and benefit inquiries?
Yes
3. Will you provide concierge customer service
support to the City?
Yes, BCBSAZ will continue to provide the City
with a both a claims and clinical concierge
service model. This program offers a
designated BCBSAZ employee that the City
may refer to for help in complex situations.
These individuals are trained to the City’s
benefits and are familiar with the multifaceted
areas these situations typically require.
4. Are questions regarding provider billing, benefits,
or member grievances covered by the same phone
number? If not, please explain.
Yes
5. What hours and days are live customer service
representatives available (indicate using AZ time)?
BCBSAZ will continue to provide the City with
customer service hours from 7 a.m. to 6 p.m.
(Arizona time) Monday through Friday
excluding BCBSAZ holidays.
Members and providers can also use self-
service channels, which include our IVR system
and azblue.com, to obtain claims status,
eligibility, and benefits information 24/7.
6. Are your customer service representatives located
in the continental US?
Yes
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
7. What alternative services do you provide? (i.e.,
Assistance for the hearing impaired, 24-hour toll-
free automated benefits and eligibility, bilingual
option, customer service accessible via the
internet, etc.).
Members may call after normal business hours
and reach our Interactive Voice Response (IVR)
system. The IVR system allows providers and
members quick and easy access to claims
status, eligibility, and benefits. Members also
can go online via azblue.com to access
eligibility, benefits, provider status and claim
status. The IVR and web access are available
24/7.
Additionally, we are committed to providing
excellent service to all our diverse members
and offer specialized services to meet their
specific needs as follows:
• Spanish Speakers—There are Spanish
Speakers throughout our customer
service teams that are ready and able to
assist members.
• Hearing Impaired— We provide service
through the 711 Telecommunications
Relay Service (TRS). TTY users may ask
the relay service to connect to our
customer service number, referencing
the number on the back of their card, or
our Toll-Free 1-800-232-2345 number.
• Visually Impaired—We assist our visually-
impaired members by working with
LanguageLine Solutions to have
correspondence translated into braille.
8. Please provide the following statistics for 2020 and
2021 (YTD):
Average speed to answer: ___% within 30 seconds
Calendar Year (CY) 2020—97.47 percent within
45 seconds
Year-to-Date (YTD) 2021 - 31.04 seconds
Busy rate: ___ seconds
This is not applicable as BCBSAZ does not busy
out or block calls.
Abandonment Rate : ___%
CY 2020—0.54 percent
YTD 2021 - 1.33 percent
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
9. Are plan participants able to access a web portal
for:
a. Status of claims
Yes
b. Benefit brochure
Yes
c. ID cards
Yes
d. Cost estimator of common services
Yes
e. Cost of services by a specific provider
No
f. Network Provider Quality
Yes
10. Can the City and their designated Consultant
access eligibility and reporting through a secure
website?
Yes
11. What kind of reports can the City retrieve online?
Reports will be available to the City using
whYzen/BlueInsightSM, our online reporting
tool, which is updated on the 20th of each
month. BlueInsight is designed to provide
comprehensive and flexible healthcare
reporting and data management capabilities.
This tool removes guesswork from managing
the City’s healthcare plan, offering hundreds of
online reports and data elements to the
client's authorized users.
whYzen/BlueInsight offers the ability to track
medical, dental and pharmacy claims-
utilization data and to perform aggregate or
detailed-level data analysis. Its features allow
quick identification of issues, trends, and
variations from benchmarks. By identifying
cost and utilization trends, groups are
empowered to make informed decisions to
meet their unique and specific needs.
Please see to Section 5W for the BlueInsightSM
flyer and Frequently Asked Questions.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
12. Please provide a temporary login/password so the
City can evaluate your tools.
A temporary login and password to the
member portal is provided below. Should the
City wish to review the employer portal or
reporting available, BCBSAZ would be happy to
provide temporary login information or a
demo.
The temporary login for the MyBlue member
and employer portals are below.
•
Member
URL: azblue.com
Login: mtrails1
Password: Password1
•
Employer
URL: azblue.com
Login: adamrice
Password: password1
Additionally, the City will have access to
standard and customizable reports using
BlueInsight, our online reporting tool.
BlueInsight is designed to provide
comprehensive and flexible healthcare
reporting and data management capabilities.
13. What methods does your organization use to
measure customer satisfaction?
BCBSAZ conducts satisfaction studies with a
statistically valid sample of employer group
customers on an ongoing basis. This survey is
currently conducted via telephone and web
through an independent research vendor.
Annually, 1,200 group members (those who
get their insurance through their employer)
participate in these studies.
14. How do your providers recognize a patient as a
participant in your program – voucher, ID card,
electronic connection to your eligibility database,
etc.? Please explain.
Members are enrolled in a network based on
the assignment of their benefit plan, which is
identified on their ID cards. Members and
providers also may verify enrollment by
accessing the BCBSAZ website at azblue.com
or calling BCBSAZ customer service.
YES
NO
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
1. When a participant calls your customer service
number, is there an option to:
a. Listen to choices in Spanish?
Yes
b. Speak with a representative who converses in
Spanish?
Yes
c. How do you accommodate a caller who needs
translation in a language other than Spanish
and English?
BCBSAZ also offer
translation services
via LanguageLine
Solutions®, a company
that offers
interpreters for over
200 other languages.
These services are
accessed through a
prompt when calling
customer service.
2.
MEDICAL NETWORK COMPOSITION
VENDOR RESPONSE
1. What is the marketing name of your network?
BCBSAZ Statewide PPO Network
2. a. If you indirectly contract with another network
inside Arizona, what is the network name and
fee you pay?
BCBSAZ subcontracts with American Specialty
Health (ASH) Incorporated for our chiropractic
network, covered services, claims processing,
appeals and grievances, etc.
b. If you indirectly contract with another network
outside Arizona, what is the network name and
the fee you pay?
BCBSAZ enrollees have access to the
BlueCard® provider network, which covers
members residing or traveling outside of
Arizona. The BlueCard program links
participating healthcare providers in all Blue
plans throughout the United States and in
more than 170 countries and territories
worldwide through a single electronic network
for claims processing and reimbursement. For
additional details, see the BlueCard and BCBS
Global Core flyer in Section 5X.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
c. If there is a fee, please confirm it is included in
your administration fee.
BlueCard program fees are not included in
BCBSAZ’s administration fees; however, we
have noted them on our rates and
assumptions in Section 2B and are also noted
here:
Access Fees:
• 2.11% in 2023 for 1,000–9,999 Blue PPO,
EPO (Self-Funded Group Health Plans
Only) or traditional enrolled contracts
Reduced Administrative Expense Allowances
(AEAs):
To be considered for reduced fees, the
Employer must exceed 1,000 PPO, EPO (Self-
Funded Group Health Plans Only) or traditional
enrolled Blue contracts:
• Professional - $4.00 per claim
• Institutional - $9.75 per claim
• Non-Participating Provider $3.00 per
claim
• Medicare related claims $1.00 per claim
• Non-standard negotiated fees can range
from either $5.48 to $15.44 per claim or
$8.50 to $21.10 per contract per month
depending on the negotiated
arrangement and/or the health plan
product.
3. Confirm that your proposed network is a national
network with coverage for out-of-state members
(i.e. retirees, students) and those that are traveling.
BCBSAZ confirms.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
4. How is coverage for out-of-state members handled? BCBSAZ enrollees have access to the
BlueCard® provider network, which covers
members residing or traveling outside of
Arizona. The BlueCard program links
participating healthcare providers in all Blue
plans throughout the United States and in
more than 170 countries and territories
worldwide through a single electronic network
for claims processing and reimbursement. For
additional details, see the BlueCard and BCBS
Global Core flyer in Section 5X.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
5. Provide a list of the Centers of Excellence for organ
and tissue transplants included in your network in
Arizona?
BCBSAZ has a comprehensive Transplant Care
Management program that supports members
with customized arrangements for covered
transplant services.
BCBSAZ participates in the Blue Distinction®
Centers (BDC) for Transplants program
through the Blue Cross Blue Shield
Association. This program currently recognizes
over 400 different centers of excellence for
transplants across the United States.
The BDC Transplants Program includes the
following types of transplants and centers of
excellence in Arizona:
•
Adult Heart – 67 centers (in Arizona:
Mayo Clinic Hospital)
•
Adult Kidney-Deceased Donor – 30
centers
•
Adult Kidney-Living Donor – 28 centers
•
Adult Lung – 39 centers (in Arizona:
Banner University Medical Center-Tucson
Campus)
•
Adult Liver-Deceased Donor – 71 centers
(in Arizona: Mayo Clinic Hospital and
Banner University Medical Center-Tucson
Campus)
•
Adult Liver-Living Donor – 17 centers (in
Arizona: Mayo Clinic Hospital)
•
Adult Pancreas – 28 centers
•
Pediatric Heart – 33 centers (in Arizona:
Phoenix Children’s Hospital)
•
Pediatric Kidney – 16 centers
•
Pediatric Liver – 25 centers
•
Adult Bone Marrow/Stem centers (in
Arizona: Mayo Clinic Hospital)
•
Pediatric Bone Marrow/Stem Cell – 46
centers (in Arizona: Phoenix Children’s
Hospital)
Providers recognized by BDC for Transplants
meet stringent clinical criteria that have been
established in collaboration with expert
physicians and medical organizations. They
also demonstrate better overall patient
outcomes.
Please see Section 5Y for a list of BCBSAZ
Centers of Excellence.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
6. Outline any anticipated network changes for:
i.
Physicians
No substantial changes.
ii.
Hospitals
No substantial changes.
7. Indicate major hospital contracts scheduled for
renewal in the next 12 months for:
In the next 12 months, the following major
hospital contracts are scheduled for renewal:
a. Maricopa County
•
Phoenix Children’s Hospital
•
Dignity Health
•
Banner Health
b. Arizona (other than Maricopa County)
•
Banner Health (facilities in Pima and Pinal
counties and some rural counties near
Payson and Page)
•
Community Health Systems facilities in
Pima County
8. List any provider-types in your network that are
compensated on a capitation basis.
BCBSAZ does not reimburse physicians on a
capitated basis.
9. How many urgent care facilities do you have in your
network that have after hours (nights and
weekends) care within the zip code of 850 and 852?
92 of the contracted 98 PPO urgent care
facilities in zip code 850 and 852 are open after
hours or provide weekend care. Counts are
based on weekday hours after 5 p.m. and/or
are open on the weekends.
10. Indicate which “walk up” clinics are in your network.
Yes. MinuteClinic and The Little Clinic of
Arizona are walk-in clinics in the PPO network.
11. Do you provide Telehealth services (24/7 access to
medical, counseling, and psychiatry services)?
Yes, BCBSAZ provides telehealth services
through BlueCare AnywhereSM.
12. Do you provide Telemedicine services (virtual visits
in lieu of physical office visits with a member’s
doctor)?
13. Have you provided electronic copies of your
proposed PPO Maricopa County network providers
in Microsoft Excel format? Fields should include
the following:
BCBSAZ confirms. See Section 4Q.
•
Provider last name (Please do not put
generation indicator i.e. Jr. III…or
designation such as MD or DO in this field)
See Section 4Q for BCBSAZ’s PPO network
providers in Maricopa County in Excel.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
•
Provider first name (Please do not combine
first and last names in the same field)
•
TIN
•
Street address (Only include physical locations
not billing addresses such as P.O. Box)
•
City
•
State
•
5-digit zip code (Some zips start with 0. Please
don’t use number format which deletes the 0)
•
Type of provider (MD, DO, etc.)
14. Please provide Geo Access reports using the
following access standards:
Your results must be based on those employees
on the census that would be eligible to elect
medical benefits (1,865 employees).
Reports should reflect city, state, zip code, and
number of unique vision providers by zip, number
of employees with desired access (as defined
below) for each category AND locations (Zip Code
and County) where access standards are not
met including the number of employees without
desired access.
Yes.
Please see Section 4N for the Statewide PPO
GeoAccess analysis report.
a. 2 PCPs within 10 miles. Include family practice,
general practice, internal medicine,
pediatricians and OB/GYN. Provider to be based
on MD, DO, or DPM designations only.
Employees with desired access: 1,843 (99.7
percent)
Employees without desired access: 6 (0.3
percent)
b. 2 Specialists within 10 miles
Employees with desired access: 1,841 (99.6
percent)
Employees without desired access: 8 (0.4
percent)
c. 1 Hospital within 20 miles
Employees with desired access: 1,816 (98.2
percent)
Employees without desired access: 33 (1.8
percent)
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
CUSTOMER SERVICE OPERATIONS
ALL PROPOSERS
VENDOR RESPONSE
(If your response differs by type of coverage
you are proposing, provide your response
for each line)
15. a. How is your online provider directory
maintained?
BCBSAZ routinely outreaches to our providers
to validate their information as part of our
directory monitoring. Providers are
responsible for responding to our inquiries in
a timely manner or they are removed from the
directory until their response is received. Any
changes identified by the provider are
generally updated within two business days.
b. How often is it updated?
Our provider directory is updated every
weekday, with the exception of holidays, to
reflect changes in the network.
c. What is your process for confirming that the
providers listed are still in your network?
BCBSAZ routinely outreaches to our providers
to validate their information as part of our
directory monitoring. Providers are
responsible for responding to our inquiries in
a timely manner or they are removed from the
directory until their response is received. Any
changes identified by the provider are
generally updated within two business days.
d. What is your process for confirming the
providers listed are taking new patients?
BCBSAZ routinely outreaches to our providers
to validate their information as part of our
directory monitoring. Providers are
responsible for responding to our inquiries in
a timely manner or they are removed from the
directory until their response is received. Any
changes identified by the provider are
generally updated within two business days.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
1. What is the marketing name of your ACO network?
Alliance Network
2. Indicate the name of the ACO(s) that you partner
with?
The BCBSAZ ACO network is anchored by
two well-established ACOs: Banner Health
Network ACO and HonorHealth Innovation
Care Partners ACO. The network includes all
hospitals, facilities, and providers affiliated
with these ACOs in Maricopa County and in
some parts of Pinal County. This network is
based on lowering costs and improving care
for the members/employer groups who
choose this network offering. As part of the
collaboration, there is a shared savings
component that incentivizes for the efficient
delivery of care. For self-funded clients,
there is a $2 per member per month care
coordination fee that applies.
3. What types of providers are part of the ACO?
The network includes all hospitals, facilities,
and providers affiliated with Banner Health
Network ACO and HonorHealth Innovation
Care Partners ACO in Maricopa County and
in some parts of Pinal County.
4. Provide examples of how members are aware, or
made aware, that they are active participants in an
ACO.
Members are enrolled in a network based
on the assignment of their benefit plan,
which is identified on their ID cards.
Members and providers also may verify
enrollment by accessing the BCBSAZ
website at azblue.com or calling BCBSAZ
customer service.
5. How does a member find an ACO provider?
BCBSAZ’s secure online member resources
include:
•
Find a provider, healthcare
professional or facility
•
Find a pharmacy
•
Check prescription drug costs with our
copay calculator
•
Use the hospital comparison tool
•
Order ID cards and download forms
6. Does a member need to select a PCP?
No
7. Does a member need a referral from a PCP in order
to visit a network specialist?
No
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
8. Are there any urgent care facilities in the ACO
network?
Yes
9. How are emergency services outside the ACO
network handled?
If a member receives emergency services
from a non-contracted facility or
professional provider, it will be covered at
the INN level of benefits. BCBSAZ will base
the allowed amount used to calculate
member cost share on the provider’s billed
charges.
For all non-emergency services following the
emergency treatment and stabilization, the
member will pay applicable cost share. The
cost share amount will depend on the
provider’s network status and the facility
where services are received. If the member
receives non-emergency services from a
non-contracted provider, the member will
also pay the balance bill, which may be
substantial.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
10. What happens if services for a certain type of
provider are not part of the ACO network?
Precertification is required regardless of the
provider’s network status. Precertification
must be obtained before receiving the
following services or medications:
•
Behavioral and mental health
outpatient services.
•
Inpatient admissions, including
hospital, long-term acute care,
detoxification, skilled nursing facility,
behavioral health and extended active
rehabilitation (emergency and
maternity admissions do not require
precertification).
•
Inpatient dental services or
procedures.
•
Lifestyle education and management
services, biofeedback and
hypnotherapy.
•
Medications covered under the
“Specialty Self-Injectable Medication”
benefit, certain medications covered
under the “Retail and Mail Order
Pharmacy” benefit (if these
medications are available under your
benefit plan) and certain medications
covered under the “Home
Health/Home Infusion” benefit. The
current list of specific medications that
require precertification is available at
azblue.com and is subject to change at
any time without prior notice.
•
Organ, tissue or bone marrow
transplants and stem cell procedures.
•
Requests for services by an out-of-
network (OON) provider for the in-
network cost share.
•
Services directly associated with a
cancer clinical trial.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
11. What happens if a child attends college outside the
ACO service area?
As a member of the Blue Cross and Blue
Shield Association (BCBSA), BCBSAZ
preferred provider organization (PPO)
members have access to nationwide
coverage through BlueCard®. The BlueCard
program gives members access to doctors
and hospitals across the country, giving
them peace of mind knowing that they will
find the care they need. Students and
dependents can get coverage if the contract
holder is based in Arizona.
12. What are the anticipated savings using your ACO?
The BCBSAZ Alliance exclusive network is
anchored by two well-established ACOs:
Banner Health Network ACO and
HonorHealth Innovation Care Partners ACO.
Savings are dependent upon member
participation.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
13. Is the saving from deeper discounts or tighter,
integrated medical management?
Tighter, integrated medical management.
BCBSAZ predictive modeling tools are used
to evaluate future and relative risk of
incurring high costs in the subsequent 12
months. An innovative mental and physical
assessment determines functional risk using
the industry-leading SF-8TM DynHA® survey
instrument.
Variables that feed into the predictive
modeling tools are primarily derived from
medical and pharmacy claims data, as well
as eligibility data. Some variables include,
but are not limited to, medical claims
amount, pharmacy claims amount, age,
gender, medical utilization, and diagnosis.
BCBSAZ uses Impact ProTM predictive
modeling tools as part of the stratification
process. After participants are initially
identified from claims, the tool determines
an initial acuity level, as well as current and
future costs and clinical status.
Regular transmission of data feeds is
established, which enables BCBSAZ to
update the predictive models. Through the
acuity movement process, claims data is
reviewed monthly and participants can
move up or down in acuity based on the
claims and referral information received.
This ensures that our vendor’s predictive
modeling maximizes the efficiency and
effectiveness of disease management
programs by enabling them to reach out to
the members at highest risk first.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
14. What quality metrics and efficiency measures are
being tracked?
BCBSAZ uses different models with the
accountable care organization (ACO)
groups. Each contract is customized for
both reimbursement and quality metrics. At
least one of the arrangements includes a
risk-sharing contract reimbursement model,
with lower unit cost and shared savings.
Others include pay for performance and
quality metrics.
Participation and utilization; program-level
outcomes. whYzen-BlueInsightSM, our self-
serve online reporting tool, is available
online. Monthly standard reports are
updated on the 20th of each month.
Program-level outcomes reports are
available annually.
15. Do you guarantee savings and if so indicate the
amount?
No
16. How are ACO providers compensated?
BCBSAZ may compensate providers based
on value-based arrangements for the
achievement of quality performance
measures. Such programs are available to
professionals and facilities. The specific
measures can be related to operational
process, access, clinical outcomes, patient
satisfaction, cost, or other types of
measures, or a combination of these. Our
incentives are customized and leveraged for
continuous improvement over time.
17. How is the City billed for the ACO?
ACO fees ($2.00 PMPM – apply to Alliance
enrolled members only) are included in the
Attachment Point rate and are charged on
the monthly invoice as a claim expense.
18. Indicate all additional fees associated with using
your ACO?
There are no additional fees outside of the
BCBSAZ administration fee.
19. Is there a true-up or year-end reconciliation if the
ACO doesn’t deliver targeted savings or meet
established metrics?
Yes
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
20. Are there any loss corridors or limits if the ACO
doesn’t meet targets?
Yes. Banner and the client will enter into a
risk share agreement. BCBSAZ will calculate
the risk sharing dollars for the group’s
employee enrollment in the Acclaim
network for each risk sharing period in
accordance with the following formula:
•
If actual claims are within +/- 5 percent
of expected claims, no risk sharing
occurs.
•
If actual claims are greater than 105
percent of expected claims, the group
is responsible for 50 percent of the
actual claims amount that exceeds 105
percent to 120 percent of expected
claims. Claims exceeding 120 percent
are not part of the risk sharing
agreement.
•
If actual claims are less than 80
percent of expected claims, the group
retains 50 percent of the difference
between the 95 percent of expected
claims and 80 percent of the expected
claims.
•
If actual claims are greater than 80
percent but less than 95 percent of
expected claims, the group retains 50
percent of the difference between 95
percent of expected claims and the
actual claims.
Expected claims will be set by BCBSAZ
based on projected enrollment numbers for
the risk sharing period.
21. Is the City liable to share any savings that may result
from using your ACO?
No
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
22. How are large claims treated in evaluating ACO
performance? What pooling level would be used (if
any)?
All claims are included in the yearly
settlement calculation when stop loss is
carved out. Please note, BCBSAZ does not
remove any large claims above the assumed
pooling level when BCBSAZ is not the stop
loss contract holder.
BCBSAZ will determine, based on the
information provided in the bid proposal, to
elect to use either manuals (i.e., claims
based on the group's demographics only) or
experience, or a combination of blending
manuals with experience in developing the
new business rates.
The pooling point that will be quoted will be
reviewed based on BCBSAZ actuarial
recommended levels.
23. Is your ACO an attribution model or product model
for plan sponsors and members?
BCBSAZ uses a product model for our
Alliance exclusive network.
24. How do you determine if the patient falls within the
defined population of the ACO?
BCBSAZ is providing responses for our
Alliance network, which is based on an ACO.
To fall within the exclusive network,
members must select a benefit plan
associated with the Alliance network.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
25. What types of reports and frequency are made
available to the City? Provide samples.
Reports will be available to the City using
whYzen/BlueInsight, our online reporting
tool, which is updated on the 20th of each
month. BlueInsight is designed to provide
comprehensive and flexible healthcare
reporting and data management
capabilities. This tool removes guesswork
from managing the City’s healthcare plan,
offering hundreds of online reports and
data elements to the client's authorized
users.
whYzen/BlueInsight offers the ability to
track medical, dental and pharmacy claims-
utilization data and to perform aggregate or
detailed-level data analysis. Its features
allow quick identification of issues, trends,
and variations from benchmarks. By
identifying cost and utilization trends,
groups are empowered to make informed
decisions to meet their unique and specific
needs.
26. How to do you take corrective steps to insure quality
metrics are achieved?
Quality metrics are monitored through
mutually agreed-upon dashboards, monthly
reports on established quality metrics, and
regular meetings focused on improving
quality and process of member care.
27. Indicate major hospital contracts scheduled for
renewal in the next 12 months for:
a. Maricopa County
Phoenix Children’s Hospital, Dignity Health,
and Banner Health
b. Arizona (other than Maricopa County)
Banner Health includes facilities in
Maricopa, Pima, and Pinal counties, and
some of the rural areas (near Payson and
Page); Community Health Systems includes
facilities in Pima County.
28. List any provider-types in your network that are
compensated on a capitation basis.
BCBSAZ does not reimburse physicians on a
capitated basis.
29. Have you provided electronic copies of your
proposed ACO Maricopa County network providers
in Microsoft Excel format? Fields should include the
following:
Yes. Please refer to document Section 4Q -
Alliance Network Providers Report.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
NETWORK – ACO
VENDOR RESPONSE
•
Provider last name (Please do not put
generation indicator i.e. Jr. III…or designation
such as MD or DO in this field)
•
Provider first name (Please do not combine
first and last names in the same field)
•
NPI
•
Street address (Only include physical locations
not billing addresses such as P.O. Box)
•
City
•
State
•
5-digit zip code (Some zips start with 0. Please
don’t use number format which deletes the 0)
•
Type of provider (MD, DO, etc.)
30. Please provide Geo Access reports using the
following access standards:
Your results must be based on those employees
that would be eligible to elect medical benefits
(1,865) employees.
Reports should reflect city, state, zip code, and
number of unique vision providers by zip, number
of employees with desired access (as defined below)
for each category AND locations (Zip Code and
County) where access standards are not met
including the number of employees without desired
access.
Yes. Please refer to document Section 4O -
Alliance GeoAccess Report.
a. 2 PCPs within 10 miles. Include family practice,
general practice, internal medicine, pediatricians
and OB/GYN. Provider to be based on MD, DO,
or DPM designations only.
b. 2 Specialists within 10 miles
Employees with desired access: 1,841
(99.6%)
Employees without desired access: 8 (0.4%)
c.
1 Hospital within 20 miles
Employees with desired access: 1,797
(97.2%)
Employees without desired access: 52 (2.8%)
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
2.
MEDICAL NETWORK CLAIMS PAYMENT
VENDOR RESPONSE
1. How is continuity of care maintained if the City were
to change to your organization?
As the City’s incumbent, BCBSAZ will ensure
continuity of care issues are minimal.
Our extensive provider network typically
offers clients seamless transitions for
members currently receiving treatment.
Our Sales and UM Departments will work
closely with your GBA to identify potential
transition-of-care issues. If necessary, prior
authorization can be arranged in advance of
the contract effective date so that care is not
disrupted.
In the event that a member’s current
provider is not contracted with BCBSAZ,
every effort will be made to ease the
transition. Depending on the individual
situation, a special contract may be
negotiated with the non-contracted provider
to continue to provide care for the affected
member. Assistance locating an in-network
provider qualified to handle specific needs is
also provided.
New members who require additional
coordination of care as they transition to the
BCBSAZ plan and network can be referred to
our care management program for one-on-
one support.
2. What penalties should the City be aware are included
in your contracts related to untimely claim payment?
Not applicable.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
2.
MEDICAL NETWORK CLAIMS PAYMENT
VENDOR RESPONSE
3. List all of the scenarios in which your discounts
cannot be applied to bills submitted by network
facilities or physicians (e.g., workers comp, third party
liability, etc.).
BCBSAZ’s provider discounts are applicable
for all covered services and all lines of
business and are always considered when
processing claims.
Provider contractual rates do not apply to
non-covered services. If a provider has a
member sign a waiver for services that could
be deemed as experimental or
investigational, then the provider is allowed
to collect billed charges. When services to
which a member is entitled under a benefit
plan also are covered under another group
health plan, BCBSAZ and the provider will
cooperate to coordinate benefits. In rare
instances where the provider’s billed charge
or the Workers Comp the Industrial
Commission of Arizona (ICA) fee is less than
our allowed fee, which includes our
discounts, we would pay the lower amount.
The total of all payments will not exceed the
provider's billed charges.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
2.
MEDICAL NETWORK CLAIMS PAYMENT
VENDOR RESPONSE
4. Do you actively negotiate out-of-network claims on
behalf of the plan or do you only apply your out-of-
network reimbursement level?
Yes, BCBSAZ actively negotiates with non-
participating providers with the goal that
they accept our out-of-network claims
reimbursement or something lower and not
balance bill the member. This applies to
claims that are not in scope for the “No
Surprises Act” (NSA).
The NSA is part of the federal Consolidated
Appropriations Act (CAA) signed into law in
2020. The NSA includes patient billing
protections effective January 1, 2022.
For plan and policy years starting on and
after January 1, 2022 (and on 2022 renewal
dates for existing clients), BCBSAZ will follow
the requirements of the NSA in reimbursing
out-of-network providers for emergency, air
ambulance, and other professional services
that are in-scope for the NSA.
• For in-scope claims, we will calculate
member cost share using the in-
network level of benefits and based on
the qualifying payment amount (QPA),
which is determined according to a
formula specified in federal rules.
• In most cases, the initial payment to
the out-of-network provider will also
be based on the QPA, less the member
cost-share amount. Providers have the
right to dispute the initial payment
amount.
5. Do you agree to pay claims as processed and bill the
City on a monthly basis for reimbursement?
BCBSAZ agrees.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
2.
NETWORK
YES
NO
1. Do you offer reciprocity arrangements for members who travel outside the service
area and need:
a. Emergency treatment?
Yes
b. Non- Emergency treatment?
Yes
2. In the State of Arizona, can your network providers deliver services for the following
specialized treatment conditions:
a. Major burns?
Yes
b. Organ transplants?
Yes
c. Bone marrow transplants?
Yes
d. Specialized cancer treatments such as Proton Beam Radiation?
Yes
e. Neonatal care?
Yes
f. Fertility treatments?
Yes
3. Are the following providers in your network:
a. Arizona Mayo Clinic?
Yes
b. Arizona Mayo Hospital?
Yes
c. Mayo Clinic’s Outside Arizona?
Yes
d. Mayo Hospital outside Arizona?
e. Cancer Treatment Centers of America?
Yes
Yes
f. Phoenix Children’s Hospital?
Yes
4. Does your network contract with Centers of Excellence for organ transplants?
Yes
5. Do you anticipate a change in the size or location of your network in the next year
that would affect the City’s population?
No
6. Are there any penalties incurred by the City when claims payments do not occur
within a certain number of days (i.e., the discount is not valid if claims are not paid
within 30 days of being submitted)?
No
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
3.
ADMINISTRATIVE SERVICES
OFFEROR RESPONSE
1. a.
Do you have the ability to administer
claims based on the City’s current plan
designs and will not ask the City to alter
any of their plan of benefits in order to
accommodate your computer systems?
Please answer yes or no only after
you have carefully reviewed the
benefit designs
Yes, as the City’s incumbent medical carrier, BCBSAZ
is able to administer claims based on the City’s
current plan designs and will not ask the City to alter
any of their benefit plans.
b. If no, list all the benefits that will NOT
be able to be adjudicated by your
claims system without some
modification in Offer Section –
Deviations and indicate your proposed
alternative. Do not simply indicate your
standard benefit provisions will apply.
2. The plan currently covers Homeopaths,
Naturopaths, Acupuncturists and
acupuncture services provided by a M.D.,
D.O. and Chiropractor. Please confirm that
you will be able to support the continuation
of this benefit.
BCBSAZ does not credential Homeopath and
Naturopath providers. We do credential acupuncture
providers for benefit plans that cover these services.
3. Indicate how you manage Coordination of
Benefits (COB):
a. Pre-payment or post-payment?
Post-payment
b. What procedures do you perform to
determine the presence of other
coverage (e.g., use claim detail, open
enrollment query, annual query, etc.)?
To determine the presence of other coverage,
BCBSAZ uses the enrollment application, claim detail
and information the provider submits.
New members complete an application that requests
information about other coverage in order to
perform coordination of benefits (COB) at the time of
enrollment. Thereafter, a letter is sent annually to
each subscriber as claims are received, requesting
updated COB information. The claim is then pended
until BCBSAZ receives COB information from the
member.
In addition, if other coverage information is
submitted on a claim by a provider and we do not
have COB information on file, the claim is held while
we obtain other coverage information necessary for
COB.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
3.
ADMINISTRATIVE SERVICES
OFFEROR RESPONSE
4. a. How is your staff informed of new State
or Federal legislation affecting a health
plan or benefit (e.g., medical, pharmacy,
etc.)?
BCBSAZ actively monitors state and federal
legislation and regulations relating to coverage
requirements and update our systems and coverage
documents as needed. Any required changes are
included on a group’s annual change sheet. BCBSAZ
does not this type of reporting.
BCBSAZ has individuals, along with members of our
Legal Department, who review new regulations to
determine whether policy or procedural changes are
required. Additionally, these and other individuals
from BCBSAZ attend national conferences and
participate in national committees focused on
compliance issues.
b. How will you inform the City of new State
or Federal legislation affecting a health
plan or benefit (e.g., medical, pharmacy,
etc.)?
When legislative developments need to be
communicated, BCBSAZ will post these temporarily
on the employer portal, and your designated
Strategic Relationship Executive (SRE) will
communicate them to the City.
5. Please provide a sample of the monthly
claims billing and administrative fees invoice.
Please see Section 5Z for sample monthly claims
billing and administrative fees invoice.
6. Please provide a sample of the monthly
accounting report for all fees paid.
Please see Section 5Z for a sample accounting
report for all fees paid.
7. Confirm you have a secure web-based
system that can be set up to accept
automatic weekly eligibility feeds from the
City’s current benefits/HRIS system, Oracle.
BCBSAZ confirms.
8. Does your system allow the City to add and
delete employees from eligibility?
Yes, the City’s Group Benefit Administrator (GBA) can
perform additions, changes, and terminations online
through the employer portal at azblue.com. In
addition, the GBA can assign roles to others so they
may perform these transactions as well or enable
employees to make the changes themselves.
Changes made by employees must be approved by
the GBA before submission to BCBSAZ. The GBA can
access a roster of all eligible members covered under
the group's plan as well as a listing of historical
transactions submitted online. They also may access
a particular individual's eligibility information using
our eligibility and benefits search feature.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
3.
ADMINISTRATIVE SERVICES
OFFEROR RESPONSE
9. Please describe your banking requirements.
BCBSAZ offers a unique banking arrangement, using
our own funds to pay your claims and then
requesting reimbursement for claims paid. This
arrangement eliminates the need for the City to have
a separate bank account to pay claims.
BCBSAZ also offers two different ways for the City to
pay administration fees and claims costs: via wire
transfer or through our employer portal. Our clients
find this saves administrative time, reduces banking
fees, and provides assurance that payments are
made based upon actual claims incurred.
10. Indicate which reinsurance/stop loss carriers
with whom you are approved to work.
BCBSAZ is willing to work with any stop-loss carrier,
with the exception of vendors owned by health
insurance companies.
11. Are all of your additional fees and charges
not covered under your basic fees detailed
on the Excel Financial Workbook?
Yes
12. The City’s plan includes subrogation. Please
explain who provides these services and the
cost for subrogation services you are
proposing.
BCBSAZ subcontracts with EXL Health, a third-party
vendor, to provide optional subrogation services for
BCBSAZ’s self-funded and governmental groups,
where permitted by applicable state and federal
laws. This contracted subrogation vendor’s fee is 25
percent of all subrogation recoveries. BCBSAZ does
not receive any compensation for subrogation
services.
Because every group is unique, BCBSAZ cannot
provide estimates of subrogation savings.
13. If a provider makes a mistake with handling
a transition/continuity of care case what will
you do to assist the plan participant in
seeking the appropriate care?
A prior authorization would be set up to review
medical necessity of the care and in-network level of
benefits for the provider, if applicable. A case
management referral would be made to assist the
plan participant in ensuring all needs are met.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
3.
ADMINISTRATIVE SERVICES - MEDICAL
YES
NO
1. When participants call your customer service number and ask questions
about the PPO network, do the representatives:
a. Provide direct answers to all issues?
Yes
b. Provide a separate number to call for further assistance with network
questions?
No
c. Provide a warm direct transfer, without interruption, to experts who then
provide answers to network questions?
N/A
2. Are bilingual versions of the following communication materials available:
a. Written?
Yes
b. Electronic?
Yes
3. Can you accept eligibility files in electronic format from the current benefit
enrollment system?
Yes
4. Does your system support on line real time eligibility inquiries by the City?
Yes
5. Do you require the City to maintain a minimum checking account balance to
pay claims?
No
6. Do you agree to financially reimburse the City for the lack of stop-loss
reimbursement the City will have incurred if you fail to take appropriate action
to pay and send claims to the stop-loss carrier within the required timeframe?
No.
BCBSAZ
requests
further
discussion
.
7. Have you noted on the Deviations Form any provisions of the current benefit
plan that you are not able to administer?
Yes
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
4.
BEHAVIORAL HEALTH
OFFEROR RESPONSE
1.
Do you have the ability to maintain an eligibility
database for pre-certification of services?
Yes
2.
Can you provide 24-hour telephonic access,
seven days a week, to crisis mental health and
substance abuse triage and counseling by
trained, licensed professionals, with all calls
logged?
BCBSAZ has Nurse On Call—A registered
nurse available 24/7/365. These professionals
are able to assist members in any health need
24/7.
In addition to this service, our internal clinical
staff have trained behavioral health specialists
that field crisis calls during regular business
hours.
Clinical staff can also use the State of Arizona
crisis line for an Arizona resident to receive
crisis services for behavioral health needs,
using the following link: Crisis Hotlines
(azahcccs.gov).
3.
Please confirm your providers are skilled in the
management of the array of mental health and
substance abuse diagnoses, including but not
limited to child abuse, rape, sexual harassment,
culturally diverse issues, conduct disorder,
psychoses, sex/marital issues, ADD, etc.
BCBSAZ confirms.
4.
Do you have the ability to adequately service
ethnic/culture/native language diversity?
key behavioral health clinical specialties (such
as depression, anxiety, substance abuse
disorder, detoxification, eating disorders, etc.)
are well represented in our network. Our
behavioral health network includes providers
who speak many languages other than English.
We educate providers to become more aware
of cultural diversity and to respect patients’
unique preferences, beliefs, and values.
5.
It is important that continuity of care be
maintained. Please describe how you will
handle transition issues with respect to moving
Behavioral Health and Substance Abuse
services from the current vendor to your firm.
At BCBSAZ, we have a continuity of care policy
and procedure that we follow for care that
needs to be transitioned from one vendor to
another.
We understand that for complex treatment
needs, changing vendors can cause concern
about disruption in care. Typically, we would
ask for information about those members in
current treatment during the transition and
work with our internal teams to seamlessly
transition care that may include care
management, utilization management,
temporarily contracting with out of network
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4.
BEHAVIORAL HEALTH
OFFEROR RESPONSE
(OON) providers and working to get OON
providers contracted in our network
permanently.
6.
Indicate the type(s) of providers that currently
have contracts with your network:
a. Physicians, counselors, all mental health and
substance abuse specialties except.
Yes. BCBSAZ contracts with the following types
of credentialed behavioral health
professionals:
•
Psychiatrist (MD and DO)
•
Psychologist (PhD and EdD)
•
Licensed Clinical Social Worker (LCSW)
•
Licensed Professional Counselor (LPC)
•
Licensed Marriage and Family Therapist
(LMFT)
•
Licensed Independent Substance Abuse
Counselor (LISAC)
•
Board Certified Behavior Analyst (BCBA)
(autism)
•
Addiction Medicine
•
Behavioral Health Nurse Practitioners
(NP)
•
Pediatric Developmental / Behavioral
Providers
These providers are licensed by the Arizona
Board of Behavioral Health Examiners and can
practice independently.
b. Mental health/substance abuse hospital(s).
Yes. BCBSAZ’s provider network includes
institutional providers offering behavioral
health services:
•
Behavioral health hospitals treating
mental health conditions
•
Behavioral subacute facilities
•
Detox and substance use facilities
•
Residential treatment centers treating
behavioral health conditions
•
Eating disorder facilities
In addition, our network is enhanced through
telemedicine for mental health disorders and
substance use. We also offer our BlueCare
AnywhereSM service for on-demand
conversations with behavioral health
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4.
BEHAVIORAL HEALTH
OFFEROR RESPONSE
professionals.
c. Other ancillary providers (describe).
See responses above in a. and b.
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4.
BEHAVIORAL HEALTH
OFFEROR RESPONSE
7.
What type of cases or specialized treatment
conditions cannot be provided by the hospitals
in your network (i.e., anorexia, bulimia, severe
psychosis, commitment)?
All key behavioral health clinical specialties
(such as depression, anxiety, substance use
disorder, detoxification, eating disorders, etc.)
are well represented in our network.
8.
Where can these services be provided?
In addition to individual provider offices,
BCBSAZ’s provider network includes
institutional providers offering behavioral
health services:
•
Behavioral health hospitals treating
mental health condition
•
Behavioral subacute facilities
•
Detox and substance use facilities
•
Residential treatment centers treating
behavioral health conditions
•
Eating disorder facilities
9.
Describe where assessment and therapy
sessions will take place (in a central location, at
individual office locations, etc.).
Assessments will take place in a variety of
locations, depending on where the provider is
located. This includes acute and subacute
facilities as well as private practice offices.
BCBSAZ has providers that offer telehealth
services through BlueCare Anywhere.
10. Do you currently have an adequate number of
staff to provide counseling services to the City?
If not, do you propose expanding your staff to
adequately cover?
Yes, as the City’s incumbent, BCBSAZ is
prepared to provide counseling services and
will evaluate staffing on an ongoing basis to
ensure adequate coverage.
11. In what situations will a counselor or provider
provide onsite assistance to patients at the
emergency department or other locations?
BCBSAZ contracts with a robust network of
providers at all levels of care including
emergency rooms, inpatient and outpatient
facilities. Many emergency room staff include
access to behavioral health professionals
including Social Workers and Psychiatrists.
Also, in Arizona, there is a statewide crisis
network that all Arizona residents are entitled
to use.
BCBSAZ’s care management program and
other staff refer to the statewide crisis services
when the situation calls for this type of
intervention. Crisis Hotlines (azahcccs.gov).
a. Is this service included in your basic fees?
Yes
b. If not, please outline any fees.
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4.
BEHAVIORAL HEALTH
OFFEROR RESPONSE
12. Exhibit D to this RFP is a Census of the City’s
employee and retirees. Are there any areas
where your providers are not available using
the criteria of 2 providers within 10 miles and 1
hospital within 10 miles?
Providers:
Employees with desired access: 1,841 (99.6%)
Employees without desired access: 8 (0.4%)
Hospitals:
Employees with desired access: 1,797 (97.2%)
Employees without desired access: 52 (2.8%)
Please see Section 5P for the mental
health/substance use GeoAccess report.
13. Indicate how many behavioral/mental health
care facilities you have in your network within
the zip codes of 850 and 852.
a. Inpatient
850 – Behavioral Health Facilities = 66
852 – Behavioral Health Facilities = 94
b. Outpatient
850 – Professional Providers = 1,943
852 – Professional Providers = 1,838
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1. MEDICAL CLAIMS PROCESSING
VENDOR RESPONSE
GENERAL INFORMATION
1. Regarding your client base in the office proposed to
service the City:
a. Number of claims administration clients you
currently serve at this location.
7,843
b. Number of total lives that these clients represent.
728,251
c. On average, how long have these clients been
under contract with you?
4.91 years
2. Claim Appeals
a. What is your process for coordinating with
independent external appeal organizations?
BCBSAZ’s appeals process complies with
state and federal laws and accreditation
standards. Members can file appeals, or
their treating providers can file appeals
on their behalf. The appeals process
applies to adverse benefits
determinations for services not yet
provided and adverse benefit
determinations of claims for services
already provided.
Members have either one or two
internal levels of appeal depending on
the product, and one external level of
appeal. The external level of appeal is
performed by an Independent Review
Organization (IRO) for self-funded
clients.
b. Indicate the name and address of the Independent
Review Organizations (IRO) used by your firm.
•
Advanced Medical Reviews, Inc.
600 Corporate Pointe, Ste. 300
Culver City, CA 90230
•
AllMed Health Care Management,
Inc.
111 SW 5th Ave Ste. 1400
Portland, OR 97204
•
Managing Care Managing Cost LLC
(MCMC)
300 Crown Colony Dr Ste 203
Quincy, MA 02169
•
Mitchell International, Inc. dba
MCN
1301 5th Ave., Ste. 2900
Seattle, WA 98101
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1. MEDICAL CLAIMS PROCESSING
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c. What is the amount of the fee for each Independent
Review that is billed to the City, if any?
BCBSAZ conducts the first one or two
levels of appeals in-house; however,
members may request an IRO review for
any level. BCBSAZ contracts with four (4)
URAC-accredited IROs, and coordination
may include level one same specialty
peer review. BCBSAZ sends the appeal
to an IRO for the external review
process, using either the grandfathered
or non-grandfathered Affordable Care
Act-compliant process or if the case is
governed under the Arizona DIFI, the
case is sent to the Arizona DIFI for
external review.
IRO fees are included in BCBSAZ’s
administrative fee.
SYSTEM CAPABILITIES
3. For claims that need additional information in order to
adjudicate (such as needing an operative report, ER
visits notes, ambulance records, student status, etc.):
a. Do you pend those claims, or deny/close the
claims?
Yes, if we require additional information
to process a claim, we will pend the
claim.
b. How long can a claim be listed as pended before
you bring resolution to that claim?
A pended claim will remain pending in
our system for a maximum of 45 days. If
no information is received at that time,
the claim is denied with a reason of “no
records received.”
PROCESSING TIME
4. Based on the most recent 6 months and including the
time the claim is with the clearinghouse), indicate:
a. Average number of calendar days to process a
clean claim from date received to date a check is
issued to the provider/patient.
r January through June 2021, our average
local, clean claim processes in 5.79 days.
Turnaround time is calculated from
receipt of the claim by BCBSAZ and the
final process date of the claim.
BlueCard® claims are not included.
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1. MEDICAL CLAIMS PROCESSING
VENDOR RESPONSE
b. Average number of calendar days to process a
claim from date received to date EOB is sent to
patient.
r January through June 2021, our average
local, clean claim processes in 5.79 days.
Turnaround time is calculated from
receipt of the claim by BCBSAZ and the
final process date of the claim. BlueCard
claims are not included.
Explanation of benefits (EOB) statements
are available online on a daily basis for
claims paid on that business day; for
members who choose to have their
EOBs mailed, they are sent every 28
days.
c. What percent of all claims submitted (regardless of
information provided on claim) have been
processed (from date received to date EOB is
issued) within 14 calendar days?
r January through June 2021, 96.49
percent of local claims are processed
within 14 days.
Turnaround time is calculated from
receipt of the claim by BCBSAZ and the
final process date of the claim. This
includes claims requiring medical
records. BlueCard claims are not
included.
d. What percent of all claims submitted (regardless of
information provided on claim) have been
processed (from date received to date EOB is
issued) within 30 calendar days?
r January through June 2021, 98.39
percent of local claims are processed
within 30 days.
Turnaround time is calculated from
receipt of the claim by BCBSAZ and the
final process date of the claim. This
includes claims requiring medical
records. BlueCard claims are not
included.
REIMBURSEMENT PROCEDURE
5. If the City has specific guidelines for multiple surgical
procedures that differs from your standard, can your
system accommodate?
BCBSAZ is unable to revise our multiple
surgical procedure pricing guidelines for
specific employer groups.
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6. Describe what, if any, hospital bill audit procedures are
in place to detect mischarges and inappropriate
charges on hospital bills and/or the miscoding of DRGs.
BCBSAZ is the medical claims
administrator; therefore, all claims,
including stop loss claims, are
adjudicated by our company.
BCBSAZ subcontracts with Change
Healthcare to perform diagnosis-related
group (DRG) and hospital bill audits.
Change Healthcare identifies which
claims to audit and requests medical
records from the provider. Discrepancies
in billing are validated with the provider
and recoveries are initiated by Change
Healthcare on any overpayments
identified. Change Healthcare’s recovery
fee is 21.5 percent of the savings
identified and collected.
Each month, a random sample of 5
claims per claims examiner/processor is
selected and reviewed. New processors
are audited at 100 percent until they
achieve 98 percent accuracy per
edit audited.
Our Internal Audit team also performs
post-payment audits, consisting of a
random selection from all claims
processed, to ensure the accuracy of
claims payments.
BCBSAZ has a prepayment review
process in place for subscriber pay
claims set to pay more than $7,000, and
for provider pay claims set to pay
$70,000 or more. Internal Audit reviews
these claims for accuracy before
payment is released.
Claims are extensively reviewed through
system edits, utilization review staff and
post payment audits. If a provider has
unusual claims, they may be reviewed
with a special audit.
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7. Is your interface with UM vendors (for decisions on
precertification, length of stay, case management, and
UR-negotiated fee discounts) electronic or paper?
Not applicable, as BCBSAZ is not offering
a carve-out option UM services. BCBSAZ
is proposing both claims administration
and UM; therefore, all information is
entered directly into the BCBSAZ system
and interface is not applicable.
8. How do you administer subrogation (pay and pursue or
pursue and pay)?
BCBSAZ pays and pursues for
subrogation claims.
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9. Explain what system you use and how you track and
document inquiries from claimants.
BCBSAZ’s claims processing system is
MetaVance® version 2.9i. MetaVance is a
fully integrated enterprise system that
allows BCBSAZ to administer benefit
programs across lines of business and
products. The MetaVance Contact
Tracking function is a new system
addition.
BCBSAZ uses the following procedures
to handle claims inquires for employees
and employers:
•
Verify the identity of the caller
•
Determine the question
•
Explain contract benefits
•
Explain how the claim was
processed, or conduct additional
research as required
•
Determine if the caller is satisfied
with the explanation or resolution
•
Arrange follow-up contact, if
necessary
Initially, all new Customer Service
Representatives (CSRs) are audited at
100 percent for claims processing
and/or phone calls. This audit continues
until a CSR has met the goal of 98
percent accuracy.
After that, our supervisors continue their
monthly audits of five claims per CSR per
month, along with two calls and three
pieces of correspondence. In addition to
the supervisors’ audits, we have a
Quality Service Coordinator who audits
three additional calls per CSR per month.
Calls regarding complaints are tracked in
our customer service processing system.
The customer’s unique identification or
the provider identification is used,
depending on the situation. Tracking
records include, but are not limited to,
the date the call was received and the
date the call was closed. Reporting can
be made available upon request.
Our Customer Service Representatives
(CSRs) are trained on claims and benefits
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1. MEDICAL CLAIMS PROCESSING
VENDOR RESPONSE
and have the ability to make real-time
claims adjustments. As such, appeals
may be handled via phone, and CSRs can
provide a response or adjust a claim on
the initial call when possible. Certain
appeals may require review by BCBSAZ
Medical Services.
1.
MEDICAL PLAN CLAIMS PROCESSING AND CAPABILITIES
YES
NO
1. Do you agree to provide summary and claim level line items detailed
accumulator data to the City’s next firm at the termination of your contract:
a. Within 30 days following termination?
Yes
b. At no cost to the City?
Yes
2. Do you agree to issue 1099’s (and W-2 forms, if applicable), to the
appropriate parties?
Yes
3. Does your EOB include:
a. Specific instructions on exactly how to appeal?
Yes
b. Specific information on the timeframes for appealing?
Yes
4. Regarding the use of Independent Review Organizations (IRO):
a. Is there a cost?
Yes
b. If yes, is it included in your Base Administration Fee?
Yes
c. Is it billed to the City?
No
5. Do you have an automated method to identify and recover overpayments?
Yes
6. Do you use a subcontracted vendor to identify and recover overpayments?
Yes
If yes:
a. Is the cost borne by the City?
No
b. Is the cost a part of your administration fee?
Yes
7. Do you have the ability to administer claims based on the City’s current
plan design(s) and will not ask the City to alter any of their plan of benefits
in order to accommodate your computer system?
Yes
8. If no, have you listed any issue on the Deviations Exhibit contained in this
RFP?
N/A
9. Are you planning to implement a new claim system in the next 24 months?
Yes
10. Do you anticipate any major enhancements to your claim system in the
next 12 months?
Yes
2.
CLAIMS SYSTEM
YES
NO
1. Do you capture/store the following data in your claim system:
a. Group policy number?
Yes
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b. City ID number?
No
c. Employee ID Number or other unique identifier?
Yes
d. Claimant ID number or other unique identifier?
Yes
e. Claimant relationship: employee, spouse, child?
Yes
f. Claimant gender?
Yes
g. Claimant data of birth?
Yes
h. Separate claims data for COBRA (self-pay) participants?
No
i.
Separate claims data for Retiree (self-pay) participants?
No
j.
Separate claims data for Temp (self-pay) participants?
No
k. Provider name?
Yes
l.
Provider type code?
Yes
m. Provider ID number (TIN and/or NPI)?
Yes
n. Provider address, city, state and zip code?
Yes
o. Type of service?
Yes
p. Billed amount?
Yes
q. Allowed amount?
Yes
r. Deductible, coinsurance and copay amount?
Yes
s. Discount amount?
Yes
t. Ineligible amount?
Yes
u. Paid amount?
Yes
v. Claim processed/date paid?
Yes
3. UTILIZATION MANAGEMENT PRE-SERVICE REVIEW
VENDOR RESPONSE
1. Indicate the toll-free number and minimum hours of
operation of your switchboard:
a. Weekdays
8:00 a.m. to 4:30 p.m. (Arizona time),
Monday through Friday.
b. Weekends
During weekend and holiday hours calls
are transferred, with instructions on how
to page the on-call RN. The calls will be
returned as soon as possible. Whenever
possible, information is obtained by
phone for review; otherwise, we request
records to be sent by fax. If the requested
services cannot be approved, a medical
director review process is initiated with
the on-call physician.
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c. Holidays
Hours are extended to 8 p.m. on Friday
evening before holiday weekends; on
Saturday, Sunday and holidays, hours are
8 a.m. to 4:30 p.m.
2. What type of system is available for receipt of pre-
service calls before/after your normal working hours?
a. Answering machine with recorded message given
Not applicable.
b. Answering machine will accept receipt of
messages
Calls received after hours, on weekends,
or on holidays via the dedicated care
management (for chronic/catastrophic
health management) line are connected
to an answering machine. The caller is
instructed to leave a message, and the call
is returned the next business day.
c. Answering service to receive messages
Not applicable.
d. Open 24 hours a day
Not applicable.
e. No provisions, except during normal business
hours
Not applicable.
3. Describe the method and frequency of notification
from your firm to the claims administrator about the
cases that have received your pre-service review and
concurrent review services.
N/A. BCBSAZ is the claims administrator.
4. Do you agree to provide prior
authorization/precertification services to the services
benefits/services which are outlined in the plan
summary?
Yes, BCBSAZ agrees.
5. How long does your pre-certification process take
from request submission to approval?
For standard requests, BCBSAZ has 10
calendar days to complete a standard
request. We typically average turnaround
in 4-5 days.
For urgent requests, we have 72 hours to
complete the request and typically
complete them same day if we have the
appropriate records available.
In addition, BCBSAZ completes skilled
nursing facility, extended active
rehabilitation, and long-term acute care
facility pre-certifications the same day if
we have records.
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6. Does your precertification program include an
analysis and determination of:
YES
NO
a. Appropriate level of care?
Yes
b. Reasonable length of stay?
Yes
c. Actual medical necessity?
Yes
d. Appropriateness of the surgery of service being
requested?
Yes
e. Necessity for a proposed pre-operative hospital
day?
Yes
f. Necessity for proposed 23-hour observation stays
following outpatient surgery?
No
7. Do you agree to attempt to redirect pre-service callers
to an appropriate in-network provider?
Yes
8. If unable to redirect to an appropriate in-network
provider, do you agree to document why?
Yes
9. Responsibility for obtaining a pre-service certification
lies with the:
a. Member?
Yes
b. Provider?
No
c. City?
Yes
10. If the service provider fails to obtain approval, is the
member responsible for any precertification penalty?
Yes
11. Do you agree to perform telephonic concurrent
review on applicable inpatient admissions, redirect to
in-network providers (when possible), and refer to
case management for additional follow-up?
Yes
12. Do you agree to notify the claims administrator
PROMPTLY, of potentially large claims that you
identify through your pre-service and case
management activity?
Yes. BCBSAZ is the
claims
administrator.
13. During case management, do you agree to direct the
patient and/or their health care providers to use in-
network services?
Yes
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14. Do you agree to provide the stop loss carrier: case
manager notes, course of treatment, pre-certification
of hospital stays, surgeries or transplants when
requested during the contract period?
No
4. CASE MANAGEMENT
VENDOR RESPONSE
1. Does your firm perform case management?
Yes. BCBSAZ practices an integrated,
holistic approach to care management
that we have been expanding over the
past couple of years. We consider the
whole person’s needs including social
determinants of health to eliminate
barriers to good health outcomes. We
have expanded our interdisciplinary staff
to include licensed professionals with
various specialties including behavioral
health, transplant, oncology, etc. We have
a robust, comprehensive assessment in
care management that considers all the
needs a member may have and conduct
care planning based on that assessment.
Our disease management programs focus
on defined member populations with the
top five conditions: asthma, diabetes,
COPD, CAD, and CHF. Disease
management programs consist of a
system of coordinated health care
interventions, interdisciplinary healthcare
professionals, and personalized
communication efforts designed to help
members manage their chronic
conditions through awareness, education,
and intervention for appropriate
treatment and lifestyle changes.
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2. How do you find cases to case manage?
Participants are identified by one or more
of the following methods:
•
Our sophisticated enterprise triage
system is updated nightly with
claims, pharmacy, and
precertification data. The system
performs predictive modeling and
stratification to identify candidates
utilizing such data as age, gender,
diagnosis, cost, and social
determinants of health
•
Identification by the utilization
review or disease management staff
•
Referral from the member’s
physician or other providers, or
employer group
•
Member self-referral
Members may qualify for more than one
care management program, either
Transition of Care or Complex Case
Management. If so, they are assigned to
the program that will meet their greatest
need first. The care manager then refers
them to other programs as appropriate.
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3. What types of cases do you identify for case
management?
BCBSAZ identifies a number of conditions
for early intervention, needing to be
screened for care coordination activities.
This list includes those diagnoses that are
considered high volume and high utilizers
of multiple resources or high-risk areas,
and which can be impacted by individual
collaboration with a case manager.
The trigger list includes:
•
High-risk maternity
•
High-risk newborns
•
Spinal cord injury
•
Cerebrovascular accident
•
Heart failure (HF)
•
Chronic obstructive pulmonary
disease (COPD)
•
Coronary artery disease (CAD)
•
Back pain
•
Arthritis
•
Catastrophic injury
•
Multiple traumas
•
Head injury
•
Diabetes
•
Asthma
•
Behavioral health conditions such
as:
○ Depression
○ Anxiety
○ Eating disorders
○ Substance use
○ Attention Deficit Disorder (ADD)
4. Do you agree to notify the stop loss carrier of
potentially large claims as they arise in the course of
these services?
Yes
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5.
MEDICAL DISEASE MANAGEMENT
VENDOR RESPONSE
1. Please check the chronic diseases
included in your disease management
program?
Proposed Programs
Available Programs
Asthma
Yes
Arthritis
Our Integrated Care
Management (ICM) program
is designed to assist
members with any health
care coordination including
chronic conditions. See more
information above regarding
this program.
Cancer
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
CAD
Yes
CHF
Yes
COPD
Yes
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Depression
Yes.
Each disease management
(DM) program identifies and
manages multiple
comorbidities to include
depression. The DM team
uses PHQ2 surveys on
routine calls and refers
members to the plan’s
behavioral health specialist
with the member’s consent.
The ICM team uses the 4 P’s,
Edinburg Postpartum
depression, and GAD7
surveys. Assessments are
evaluated, and participants
are referred to behavioral
health services as
appropriate. Additionally,
within our case management
department, we have care
managers who specialize in
Behavioral Health and many
other conditions.
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Diabetes
Yes.
Additionally, Onduo is an
innovative virtual care
program available that is
dedicated to bringing the
most up-to-date care to
people everywhere who are
living with type 2 diabetes.
Onduo functions as the day-
to-day support between
office visits and combines
diabetes tools, coaching, and
clinical support to help
members take control of
their type 2 diabetes.
Participants are supported
by the Onduo clinical team,
which consists of live
conferences with board-
certified endocrinologists as
needed as well as ongoing
coaching from Certified
Diabetes Educators and
health coaches. Participants
will also receive personalized
recommendations,
resources, and information
needed to manage their
diabetes and answer their
questions. The unique
content is designed to be
action-oriented, practical,
and sensitive to the daily
decisions that people living
with diabetes are constantly
forced to make. Onduo is
available at an additional
cost.
Eating Disorders
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
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Epilepsy
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
End-stage Renal Disease
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
General Maternity
Yes
High-risk Maternity
Yes. High risk pregnancy case
management is performed
by our Integrated Care
Management (ICM) team.
Additionally, BCBSAZ has
partnered with Sharecare®
and Ovia Health® to bring a
suite of programs that
support women and families
throughout the entire
parenthood journey
including fertility, pregnancy,
and parenting. With the easy-
to-use Sharecare app,
members have access to
Ovia Health’s expert content,
health insights tailored to
their unique needs, and
unlimited one-on-one health
coaching with their dedicated
well-being team of experts.
Hypertension
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
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Hypocholesteremia
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
HIV/AIDS
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
Low Back Pain
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
Lupus
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
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Musculoskeletal
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
BCBSAZ is additionally
implementing Hinge Health
as a pilot for another large
self-funded customer. Hinge
Health provides a patient-
centered Digital Clinic for
back and joint pain
combining a wearable-
sensor guided exercise
therapy with one-on-one
physical therapists (PTs),
health coaching, and patient
education. Hinge Health has
clinically validated outcomes
across four peer-reviewed
studies showing reductions
in: chronic pain, opioid use,
anxiety, depression,
absenteeism, and costly
surgeries. BCBSAZ would be
willing to support City of
Chandler to be added to this
pilot and can provide buy-up
pricing if this is a program
that customer is interested in
exploring.
Multiple sclerosis
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
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Obesity
Our Integrated Care
Management (ICM) program
is designed to assist
members with any health
care coordination including
chronic conditions. See more
information above regarding
this program.
Scale Back is a 12-month
interactive, telehealth-based
weight loss and lifestyle
change program as well as a
Centers for Disease Control
(CDC)
-recognized diabetes
prevention program
available at an additional
cost. The year-long program
helps participants lose 5–7
percent of their body weight,
increase their physical
activity level, and can
significantly reduce the risk
of developing Type 2
diabetes. This innovative
program uses the diabetes
prevention curriculum
developed by the CDC to
promote healthy lifestyle
changes and lasting results.
Scale Back is available at an
additional cost.
Osteoporosis
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
Weight Complications
Our ICM program is designed
to assist members with any
health care coordination
including chronic conditions.
See more information above
regarding this program.
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Other – specify
2. What claims data do you utilize to
identify potential candidates for the
disease management program?
Medical only
N/A
Prescription drugs only
N/A
Medical & prescription drugs
Yes
Other – Specify
3. Will you have a dedicated clinical
advocate for the City to support this
program?
Yes. BCBSAZ currently provides a dedicated clinical
advocate for the City and will continue to do so.
4. Do your proposed program fees
represent an “Opt-in” or an “Opt-out”
program (client prefers an Opt-In
model)?
BCBSAZ utilizes a combination of both opt-in and opt-out
participation options within the disease management
(DM) and care management programs. Reaching out to
members while also enabling referrals into the programs
has yielded excellent results.
In 2021, the care management member engagement rate
was 95 percent.
5. a. What methods and measures will
you
use to determine the
effectiveness of your Disease
Management Program with the City?
Your Health Promotion Executive (HPE) provides wellness
consultation and acts as the subject matter expert in the
development, implementation, and evaluation of worksite
wellness programming. The HPE’s primary role is to create
an individualized, comprehensive strategy designed to
engage employees and meet the City’s wellness and DM
goals and objectives.
BCBCSAZ will provide monthly and quarterly reporting.
The PG chart provided below is reported quarterly.
b. What is the anticipated ROI for a
group this size?
Please refer to the Annual DM Summary Report details
below. We do have the ability to provide quarterly reports
upon request. ROI report is provided annually.
6. Which of the following describes the
customer service relationship the
participants will have access to while
enrolled in the program?
One nurse care manager
No
Team approach
Yes
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Other – Specify
N/A
7. Are reminders sent on a routine
schedule to members and/or
participants to motivate appropriate
health actions (e.g., obtain certain
tests, schedule follow-up exams, etc.)?
Yes
8. Do you provide tele-monitoring
services?
BCBSAZ offers telemonitoring devices to qualified
members in programs for CHF, Coronary Artery Disease,
COPD and Diabetes. These devices are a targeted
intervention for qualified members who are in need of
items such as scales for CHF as well as other biometric
devices. Real-time data is sent to the monitoring center,
and outbound calls are initiated (if necessary) based on
the data. Any significant findings are reported to the
member’s provider via our provider’s report.
9. What accreditations does your
disease management program hold?
BCBSAZ has provided case management since 1994 and
achieved national accreditation from URAC in 2002.
BCBSAZ was recently surveyed and was found to be 100
percent compliant with the URAC standards, resulting in
full accreditation status through February 2024.
We require our case managers to be licensed, registered
nurses with a minimum of three years’ clinical practice
experience. Our nurses have a variety of specialty
experience in specialties such as oncology, cardiology,
neonatology, rehabilitation, etc., or have utilization/case
management experience. Our case managers have an
average of 16 years’ experience, thus having the skills and
expertise to combine industry standard goals with the
patient’s personal goals.
BCBSAZ departments that have member/provider contact
have procedures in place to address complaints and
reconsideration requests and a vehicle to handle
emergent or urgent situations in an expeditious manner.
Policies and procedures are in compliance with the
applicable state, federal and/or accreditation
requirements.
BCBSAZ offers a robust NCQA-accredited population
health DM program. In addition to our traditional DM
program, chronic care management is integrated through
the BCBSAZ Patient Centered Medical Home (PCMH)
program. This program is based on a care delivery model
designed to improve patient care outcomes by
incentivizing providers to practice high-quality, evidence-
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based medicine. It focuses on increased accessibility,
compliance with standards of care, delivering more
coordinated care, and promoting relationship-based
partnering with patients and their families. Provider
participation is grounded in outcomes-based metrics that
can be measured. Physicians who participate in the PCMH
program are measured on chronic condition (disease)
management metrics for asthma, diabetes, COPD, CAD,
HF, and hypertension. They are measured on compliance
with HEDIS metrics, managing high-risk members and
closing risk gaps, and utilization measures, including
admits per thousand and ER visits per thousand. They
also are measured on access and availability, generic drug
rates, and other measures as defined by the PCMH
program.
10. Do you provide a performance
guarantee for your disease
management services? If so, please
specify.
No. BCBSAZ does not provide a performance guarantee
for your disease management services.
11. Do you provide a health guarantee to
reduce the health risk of the client’s
population? What metrics are used?
What form of advocacy is used?
No, BCBSAZ does not offer a health guarantee at this
time.
5.
DISEASE MANAGEMENT
YES
NO
1. Have you included information in your response regarding all of the Disease
Management Programs that you are offering to the City?
Yes
2. Are you willing to include performance guarantees based on the effectiveness of
your Disease Management Program?
Yes
3. Do you agree to provide reports of DM activity and gaps in care at least quarterly
(within 30 days of the close of the month) and an annual ROI within 3 months of
the close of the prior year?
Yes
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1. Provide a description of your proposed wellness
program for the City.
In 2020 BCBSAZ launched our new
Digital Wellness Platform Solution
Sharecare. With this transition to
Sharecare, health assessments are now
managed through this digital platform
via a participant's RealAge® Test.
Members start by taking the RealAge®
Test health assessment to get a
measure of the true age of their body in
terms of health and vitality, versus their
calendar age. The program then
delivers personalized insights,
challenges, daily tracking, and one-of-a-
kind tools to help member reduce their
RealAge and live healthier, no matter
where they are in their health journey.
They can also learn what they need to
be healthier with tips on how to eat
better, exercise smarter, reduce stress,
and more. The Sharecare app
recommends simple things for them to
do every day and reminds them to do
them.
In addition, Sharecare’s RealAge
Program encourages members to take
small action – establishing tiny habits –
to build your confidence and lead to
achieving their goals. These self-paced
digital coaching programs measure
your progress in terms of improvement
in the data recorded in the related
tracker. Members can access
personalized videos and articles related
to the focus are you selected in your
timeline on the homepage. This helpful
health content is updated regularly, so
check back often. Features of the
RealAge Programs include setting goals,
identifying barriers, taking action steps,
trackers and health content.
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2. Does your proposed wellness program include an online
app? If so, please provide additional information on the
app and what services are provided.
Yes. BCBSAZ is offering the City's
medical plan enrolled members with
our enhanced wellness platform and
application (app) solution provided
through our partnership with
Sharecare.
Sharecare is a digital health company
providing a digital health solution with
high touch coaching and partner
programs that allows people to manage
all their health in one place.
The following components are included
in the BCBSAZ wellness solution at no
additional cost:
•
The RealAge® Test—A scientific
based assessment that is simple
and easy to take online or within
the app, which shows a
participant's true body age
•
Onsite Biometric Screenings
•
RealAge Programs—Digital
coaching
•
Nurse On Call—A registered
nurse available 24/7/365
•
Blue365® Discounts—Discounts
on exercise centers, weight-loss,
LASIK eye surgery, and much
more
•
BlueCare AnywhereSM—
Telehealth services enabling
virtual visits with physicians,
counselors and psychiatrists using
a smartphone, tablet, or computer
•
Fertility, Pregnancy, and
Parenting Programs—We’ve
partnered with Sharecare and
Ovia HealthTM to bring a suite of
programs that support women
and their partners throughout the
parenthood journey including
fertility, pregnancy, and parenting.
With the easy-to-use Sharecare
app, members will have access to
Ovia Health’s expert content and
tips, personalized health insights,
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and unlimited health coaching
with registered nurses
For those needing more attention and
care, we have several clinical programs
that our medical directors directly
oversee. Those programs include:
•
Care Management—Helps
members navigate the healthcare
system and health plan benefits
for their catastrophic event or
diagnosis
•
Transition of Care—Helps
members coordinate their care
after a hospital stay, helping
avoid complications and re-
admittance.
3. What methods and measures will you use to determine
the effectiveness of your Wellness Services offered to the
City?
BCBSAZ provides reporting to assist
groups with monitoring claims cost and
utilization. We also provide an annual
benchmark report, summarizing the
program performance, including
participation, financial and clinical
outcomes.
4. Did your firm develop its wellness services, merge with
or acquire a company that was performing wellness, or
do you currently work in conjunction with another firm
that actually performs the wellness services?
BCBSAZ is offering the City's medical
plan enrolled members with our
enhanced wellness platform and
application (app) solution provided
through our partnership with
Sharecare.
Sharecare is a digital health company
that helps people manage all their
health in one place. It is a digital health
solution with high touch coaching and
partner programs that allows people to
manage all their health in one place.
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5. Describe the wellness program that you have in place for
your own employees including any incentives.
BCBSAZ has provided a robust wellness
program for our own employees for
many years. We currently have a
Customized Outcomes Rewards Points
Tracking program that rewards
employees for healthy outcomes and
participation.
To receive a $30 discount per paycheck
on an employee’s health insurance
premiums, our employees do the
following:
•
Step 1 – Complete the RealAge®
test (50 points)
•
Step 2 – Fasting Health Screening
(50 points)
•
Step 3 – Achieve an additional 150
points from the Step 3 list of
options
○ 50 points for each health
measure in HIP goal range
(low risk ranges)
▪
Systolic Blood Pressure:
≤ 119 − Diastolic Blood
Pressure: ≤ 79
▪
Cholesterol Ratio: ≤ 3.4
− BMI: 18.5 – 24.9
▪
Waist Circumference:
Women ≤ 34, Men M ≤
39
○ Physician Attestation
(Doctor’s note): 150 points
○ Monthly challenges, Annual
wellness exam & preventive
screenings, Lifestyle
Coaching, Employer Activity
Programs. (25 – 100
pts/each)
To summarize, if our employees get a
biometric screening and complete the
RealAge Test, and if all their biometrics
are in the healthy range, then they have
earned their 250 points and they
achieved their premium discount. If
some of their biometrics are not in
range, then they can participate in
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WELLNESS SERVICES
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some of the other programs, such as
coaching, preventive exams, challenges,
etc. to earn the rest of their 250 points.
6. Please provide a specific example of how your
organization was able to successfully provide wellness
services to a client with employees at multiple locations.
BCBSAZ has a number of employer
groups with which we have successfully
implemented wellness services with
multiple locations, even in multiple
states. We offer onsite biometric
screening events and flu shot clinic
(minimum participation required by the
vendor) at multiple locations. Members
can also get biometrics done at local
labs, at their PCP’s office, or BCBSAZ
can send out home test kits.
In addition, BCBSAZ can provide the
option of educational webinars (the City
chooses the topic from more than a
dozen available) presented to multiple
locations simultaneously (extra fee may
be charged). We also have the Blue365®
Discount program that included fitness
center programs such as Tivity Fitness
Your WayTM or GymPass, that allow the
member to gain access to 10,000+
fitness centers nationwide for one low
monthly membership fee.
BCBSAZ can assist with marketing
materials for all our wellness offerings
that the City’s wellness committee can
send out to their employees.
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7. Please describe any new or innovative programs or
services that are in development and scheduled for
release within the next 12 months.
Our BCBSAZ team has certified Mental
Health First Aid instructors to teach the
evidence-based class to employer
groups. Mental health first aid teaches
you how to identify, understand and
respond to signs of mental illness and
substance use disorders. This training
gives you the skills you need to reach
out and provide initial support to
someone who may be developing a
mental health or substance use
problem and help connect them to the
appropriate care. Additional fee
required.
In addition, our wellness partner,
Sharecare, is constantly innovating and
upgrading their offerings and will
continue to improve our wellness
programs.
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8. Do you have ideas on other types of wellness support
items the City should consider?
Our team provides strategic corporate
wellness planning and programming
including incentive design. Our health
promotion executives can assist with
guidance with incorporating lactation
rooms, rest and relaxation room, onsite
walking paths, nutrition in the
workplace, onsite flu clinics, biometric
screenings, walking competitions, and
more.
The City can consider encouraging their
members to register for the Sharecare
wellness app and promote the RealAge
Test. The RealAge Test, Sharecare’s
dynamic and clinically validated health
risk assessment, uniquely provides
each individual with their RealAge, a
single metric for health that is both
intuitive and motivating. The RealAge
shows individuals the true age of their
body (based on health history, lifestyle
choices,) compared to their calendar
age.
The City might offer OnduoTM—Onduo
is an innovative virtual care program
dedicated to bringing the most up-to-
date care to people everywhere who
are living with Type 2 diabetes. Onduo
functions as the day-to-day support
between office visits and combines
diabetes tools, coaching, and clinical
support to help members take control
of their Type 2 diabetes. Participants
are supported by the Onduo clinical
team, which consists of live conferences
with board-certified endocrinologists as
needed as well as ongoing coaching
from Certified Diabetes Educators and
health coaches. Participants will also
receive personalized recommendations,
resources, and information needed to
manage their diabetes and answer their
questions. The unique content is
designed to be action-oriented,
practical, and sensitive to the daily
decisions that people living with
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diabetes are constantly forced to make.
(An extra fee is required).
9. Are there any specific administrative procedures or
information your firm would need from the client prior
to the implementation of your program?
The access to our Sharecare wellness
platform is handled automatically when
BCBSAZ uploads the City’s Eligibility File
to Sharecare. Therefore, as long as the
City has included the members
(employees and covered dependents)
on the Eligibility File, those members
will have access to the Sharecare
wellness tools, Lifestyle Coaching,
OviaTM Fertility, Pregnancy and
Parenting programs, Blue365
Discounts, etc.
If the City would like to have an onsite
flu shot clinic or biometric screening
event, we would need information such
as location address, contact name,
email and phone number, preferred
dates/times for the events, as well as
estimated number of participants at
each location. BCBSAZ can provide
marketing materials that the City can
use to promote the event, but we would
need the City to promote the events to
their employees.
In terms of developing a wellness
program for the City, Jessica Dunn, your
HPE, will be happy to meet with your
Wellness Committee or HR Team to
discuss goals and objectives and
coordinate an engaging and effective
wellness program.
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10. List two (2) of your wellness program ideas about how
you propose to help the City’s employees change their
behavior related to EACH of the following risk factors:
a. excessive weight
BCBSAZ offers several online tailored
behavioral change programs including
weight loss assistance. In addition,
members can engage in an online
weight loss or healthier diet virtual
coaching program (RealAge Program) or
working one-on-one with a coach in our
Lifestyle Coaching program. Coaches
can work with a member to establish
eating plan that fits the members
lifestyle and condition. Depending on
the group's medical benefit program,
counseling with a Registered Dietician
or Nutritionist may also be available for
members with certain medical
conditions or diagnosed with obesity.
In addition, for an extra fee, the City can
provide the Scale Back program, a 12-
month weight loss and lifestyle change
program designed for people who may
be at risk for diabetes. Scale Back is an
interactive, telehealth-based program
that helps participants lose 5-7 percent
of their body weight, increase their
physical activity level, and significantly
reduce the risk of developing Type 2
diabetes and associated chronic
diseases. This innovative program uses
the same diabetes prevention
curriculum developed by the Centers
for Disease Control (CDC).
Members receive a free wireless scale
upon enrollment and after attending
two classes, receive a free Fitbit
InspireTM activity tracker. Members can
attend 26 live video coaching sessions
with a registered dietitian and interact
with other members in the class for
encouragement and support. One
unique feature of the program is the
ability for the member to upload a
photo of their own meal and receive
feedback from a registered dietitian on
that meal.
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b. smoking
Members who wish to quit smoking or
other tobacco use may engage in our
Lifestyle Coaching program, working
one-on-one with highly trained and
qualified experts with degrees in
various fields such as nutrition,
psychology, public health, etc. In
addition, members can utilize a number
of educational videos, articles and
interactive tools on the Sharecare
wellness platform.
In addition, depending on the City’s
medical benefit program, certain
tobacco cessation medications such as
Chantix medication and nicotine
patches and gum may be provided to
members at no out-of-pocket cost. We
encourage employers such as the City
to promote these benefits to their
members.
c. elevated blood pressure
BCBSAZ offers a Condition
Management program for Coronary
Artery Disease (CAD) that assist those
members that may have elevated blood
pressure and other CAD symptoms. In
addition, members can work with a
Lifestyle Coach to improve factors that
may raise blood pressure, such as
stress, nutrition, and tobacco use.
Coaches have access to more than 200
personalized data attributes in the
member's person health profile (as well
as member's timeline) giving them a
comprehensive view of behavioral,
lifestyle and available claims
information.
The Sharecare platform has numerous
articles, videos, and interactive tools
that members may use to learn more
about their condition and take
educated action to improve their
condition.
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d. no regular exercise
Members can work with a Lifestyle
Coach to improve their physical activity.
Coaches are trained in motivational
interviewing techniques and can work
with a member to develop an exercise
plan that fits the members lifestyle.
Coaches check in on the member on a
regular basis to measure progress and
provide motivation and
encouragement.
Members can also participate in a
RealAge Program, a digital coaching
program. The best way to make real,
lasting behavior change is to start
small. The RealAge Program
encourages members to take small
action – establishing tiny habits – to
build their confidence and lead them to
achieving their goals.
e. elevated cholesterol/lipids
BCBSAZ offers a Condition
Management program for Coronary
Artery Disease that assist those
members that may have elevated
cholesterol/lipids and other CAD
symptoms. In addition, members can
work with a Lifestyle Coach to improve
factors that may raise blood pressure,
such as stress, nutrition, and tobacco
use. Coaches have access to more than
200 personalized data attributes in the
member's person health profile (as well
as member's timeline) giving them a
comprehensive view of behavioral,
lifestyle and available claims
information.
The Sharecare platform has numerous
articles, videos, and interactive tools
that members may use to learn more
about their condition and take
educated action to improve their
condition.
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f. stressed, depressed, anxious
BCBSAZ has Care Managers who
specialize in behavioral health who can
assist members with issues such as
stress management, depression, or
anxiety.
In addition, our Sharecare app has
many resources to assist with these
issues including articles, videos, and
interactive tools. One of the tools
available includes long-play videos with
soothing music, such as an ocean scene
or a walk through the forest.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
7.
STOP LOSS COVERAGE
OFFEROR RESPONSE
1.
Indicate what legal entity is providing the
stop loss coverage, and their relationship
to the administrator.
BCBSAZ is providing integrated stop loss with our
proposed administrative services contract for self-
funded groups. BCBSAZ will serve as administrator.
2.
a. Has your organization read and do
you agree to administer stop loss
insurance in accordance with the
plans as described in the
attachments?
Yes. Determination for eligibility, covered expenses,
etc., will be consistent between BCBSAZ's plan
document and the stop loss contract.
b. If no, please explain any deviations.
3.
Describe any underwriting contingencies.
BCBSAZ underwriting contingencies include:
•
Assumes enrollment of 1,728
•
Reserves the right to adjust rates to the first
day of any billing month in which enrollment
varies by more than 15 percent of that figure
•
Assumes we are not carving out pharmacy and
stop-loss
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
7.
STOP LOSS COVERAGE
OFFEROR RESPONSE
4.
Describe your renewal calculation.
The ICAP rates are calculated based on a blend of
manuals (i.e., claims based on the group's
demographics only), as well as the group’s estimated
incurred claims and the rating trend at the time of
the renewal calculation.
The amount of credibility (based on group size)
applied to the group's experience will be determined
at the time the renewal is calculated.
As this group has 1,700 members, we apply 100
percent credibility to the experience and use only 12
months of claims data. Once the expected claims are
determined, we add a 25 percent corridor for the
total ICAP rates.
BCBSAZ also includes fixed expenses, which is
specific stop loss, aggregate stop loss, commission,
and administrative charges.
The stop-loss charge component is based on a
combination of demographics, historical, and
projected large claims experience, including pending
large claims.
Aggregate stop loss charge is based off projected
claims. Performance of the aggregate claims is also
taken into account.
Commission, if applicable is added to the total fixed
costs.
Administrative expenses are also added to the total
fixed costs.
Expected liability is the expected claims plus fixed
expenses.
Maximum liability it the ICAP claims plus fixed
expenses.
5.
Do you agree to administer stop loss
insurance in accordance with the plans’
experimental and medically necessary
definitions, as described in the plans?
The administration of the Stop Loss Contract is
based on BCBSAZ medical benefits contract. The
medical contracts will determine what eligible
benefits will apply towards Stop Loss. Specifically
regarding the plan’s experimental and medical
necessary definitions, BCBSAZ will use the wording
within the contract to determine if that procedure is
eligible for Stop Loss reimbursement.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
7.
STOP LOSS COVERAGE
OFFEROR RESPONSE
6.
Are there any individuals being excluded
from coverage, or provided different or
limited coverage under your contract?
BCBSAZ does not typically laser individuals.
7.
If awarded the stop loss contract, do you
require completion of a disclosure
document?
No
8.
Does your contract allow you to limit or
exclude coverage on covered persons at
renewal?
Yes, we reserve the right to laser (limit) coverage on
covered persons at renewal.
9.
Do you require a disclosure statement be
completed at renewal?
No
10. If a disclosure statement is required to be
completed, what is the maximum number
of days in advance of the effective date it
can be completed?
N/A
11. Will you accept the data from the claims
payor directly?
Yes, BCBSAZ would serve as the claims payor.
12. Define clearly the terms and conditions of
your contract as they apply to
termination.
BCBSAZ is quoting a 12/24 contract. We cover runout
for 24 months following termination.
13. After termination, what is the maximum
number of days allowed for submission
of a valid claim that was incurred within
the contract period?
For a period of 24 months following the termination
of this agreement (the "run-out period"), BCBSAZ will
continue to process and pay claims incurred prior to
the termination of the agreement, in accordance
with the terms and conditions, provided the City
funds such claims and pays the fees related to claims
processing and network access.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
14. Does your program include access to
transplant centers of excellence so the
City can utilize any pre-negotiated
discounts?
Yes. BCBSAZ has a transplant program with special
arrangements for transplants at the following local
facilities:
•
Banner University Medical Center (formerly
known as Banner Good Samaritan Hospital),
Phoenix
•
Mayo Clinic Hospital, Phoenix
•
Banner University Medical Center, Tucson
•
St. Joseph’s Hospital (kidney, lung and liver),
Phoenix
•
Phoenix Children’s Hospital
•
Banner Gateway Medical Center, Gilbert
•
HonorHealth Scottsdale Shea Medical Center
(formerly known as Scottsdale Healthcare
Shea), bone marrow only, Scottsdale
BCBSAZ also participates in the Blue Distinction®
Centers for Transplants through the Blue Cross and
Blue Shield Association (BCBSA), which offers more
than 100 different centers across the United States.
The Blue Distinction Centers for Transplants
program includes the following transplant types:
•
Heart
•
Lung (deceased and living donor)
•
Combination heart-bilateral lung
•
Liver (deceased and living donor)
•
Simultaneous pancreas-kidney (SPK)
•
Kidney-only in conjunction with SPK
•
Pancreas after kidney (PAK)/pancreas alone
(PTA)
•
Combination liver-kidney
•
Bone marrow/stem cell (i.e., autologous and
allogeneic)
Blue Distinction is a designation awarded by Blue
Cross and Blue Shield companies to medical facilities
that have demonstrated expertise in delivering
specialty quality healthcare.
Additional value-added services provided within our
Blue Distinction network include:
•
Global pricing
•
Financial savings analysis and global claims
administration support
•
Referral management
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
7.
STOP LOSS COVERAGE
OFFEROR RESPONSE
•
Transplant-related continuing education
programs for members
BDSC currently includes eleven areas of specialty
care:
•
Bariatric surgery
•
Cancer care
•
Cardiac care
•
Cellular immunotherapy (CAR-T)
•
Fertility care
•
Gene therapy
•
Knee and hip replacement
•
Maternity care
•
Spine surgery
•
Substance use treatment and recovery
•
Transplants
Today, more than 4,900 Blue Distinction and Blue
Distinction Center+ designations have been awarded
to more than 2,100 facilities and providers spanning
50 states and District of Columbia (D.C.) and Puerto
Rico.
15. What is your current leveraged trend for
a $350,000 deductible?
BCBSAZ’s current leveraged trend for a $350,000
deductible is 17.41 percent.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
8.
HEALTH SAVINGS ACCOUNT
VENDOR RESPONSE
1.
a.
What is the name of the HSA administrator
(i.e. the Medical TPA, a contracted partner)?
BCBSAZ partners with HealthEquity® to
provide HSA administration. HealthEquity is
located in Draper (Salt Lake City), Utah.
b.
Are you a qualified HSA trustee or
custodian?
Yes, HealthEquity is an IRS-authorized
nonbank custodian, serving as an
independent and trusted partner to
consumers seeking to manage, save, and
spend their healthcare dollars. As a
nonbank custodian, we are permitted to
hold HSA dollars on behalf of
accountholders by meeting requirements
outlined by the U.S. Treasury. Nonbank
custodians are required to affirm their
status annually with the Employee Plans
Compliance Unit of the IRS. Other than
amounts that the participants direct us to
move into investment funds, HealthEquity
contracts with various FDIC-insured
depositories.
c.
Please explain the basis for your
qualifications and the dates of qualification.
BCBSAZ contracted with HealthEquity® in
2009 to offer health savings account (HSA)
administration services to employer groups.
Based in Salt Lake City, Utah, HealthEquity
was founded in 2002 and has been offering
HSA administration services since 2004.
In 2011, BCBSAZ expanded our relationship
with HealthEquity the relationship to include
flexible spending accounts (FSA) and health
reimbursement accounts (HRA)
HealthEquity is committed to serving as an
independent and trusted partner to
consumers who are seeking to manage,
save, and spend their healthcare dollars. As
an Internal Revenue Service (IRS) authorized
nonbank custodian and the administrator of
our products, HealthEquity is able to provide
in-house oversight and management that is
distinct to our industry, from enrollment to
contribution to ongoing use. This is only
possible because we work closely with a
variety of well-capitalized financial
institutions to ensure funds associated with
HealthEquity accounts are securely held and
eligible for both Federal Deposit Insurance
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
Corporation (FDIC) and the National Credit
Union Share Insurance Fund (NCUA)
insurance.
2.
How long have you provided HSA administration
services?
HealthEquity was founded in 2002 and has
been offering HSA administration services
since 2004. BCBSAZ contracted with
HealthEquity® in 2009 to offer HSA
administration services to employer groups.
3.
What information or administration services for
HSA’s are available on your website?
Employers and members benefit from
HealthEquity’s proprietary web capabilities
featuring:
Member Portal
HealthEquity’s member portal website is
designed to help employees understand
how their health plan and healthcare
accounts work together as part of their
overall health benefit. Our user-friendly
website features present members with
various resources that assist with
determining how to best spend or save their
healthcare dollars. Our website offers
helpful tools; whether members simply
need information or are interested in paying
claims or reimbursing themselves from their
accounts, they can do so from the member
portal. Members can also modify
contribution accounts to their HSAs at any
time during the plan year:
•
Access account balance information
•
Monitor interest rate on cash account
•
Access investment desktop/manage
investments
•
Access the HealthEquity online
payment platform to request
reimbursement or to submit payment
to a provider
•
View account contributions
•
Make HSA contributions
•
Access various tools, links and forms.
•
Download 1099-SA and 5498-SA tax
forms
•
View monthly on-line statements
•
Designate a beneficiary
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
•
Add an external bank account from/to
which the member can make
contributions and receive distributions
•
Opt-in/opt-out of various member
emails
For members who choose to invest their
HSA funds, HealthEquity provides a
completely integrated investment
experience, members do not have to log out
and log into a separate investment site. We
offer a user-friendly investment desktop
where employees can elect to either
manage their investments on their own or
subscribe to a web advisory tool called
Advisor™ to receive advice and ongoing
oversight. Employees who elect to manage
their own HSA portfolio can analyze and
choose funds, set target allocations, and
track the performance metrics of their
holdings.
Employer Portal
HealthEquity’s employer portal provides full
visibility and control for viewing reports,
paying invoices, managing account setup,
and determining funding and banking
arrangements. Through the employer portal
website, we offer service features that
surpass many other HSA administrators,
including the following:
•
Viewing various reports
•
Setting up employer contributions
•
Managing employee HSA contributions
•
Paying fees
•
Adding access for other authorized
users
4.
Do you have a call center available to answer
questions telephonically?
Yes. HealthEquity delivers customer service
from U.S. based employees dedicated to
answering member inquiries. Customer
service is available every hour of every day.
HealthEquity Member Service
Representatives are available 24/7/365 via
our toll-free phone number. Additionally,
members can access our expanded chat
options and interactive voice response (IVR)
system. This provides immediate support
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
and convenient access to account
information.
5.
Name the qualified HSA custodians/trustees
(e.g. banks and insurers) with which you have a
relationship and describe that relationship.
HealthEquity is an IRS-authorized nonbank
custodian, serving as an independent and
trusted partner to consumers seeking to
manage, save, and spend their healthcare
dollars. As a nonbank custodian, we are
permitted to hold HSA dollars on behalf of
accountholders by meeting requirements
outlined by the U.S. Treasury. Nonbank
custodians are required to affirm their
status annually with the Employee Plans
Compliance Unit of the IRS. Other than
amounts that the participants direct us to
move into investment funds, HealthEquity
contracts with various FDIC-insured
depositories.
6.
What services and reporting can the City and its
employees expect from the HSA
custodian/trustee?
HealthEquity offers employers an online
employer portal to access self-service
features and on-demand reporting.
Standard reports include:
•
Account Summary—Displays account
summary, including number of
employees with a zero balance,
average balance, maximum dollar
amount within any employee account,
employees with balances greater than
$2,500 and the number of employees
balances within various ranges.
•
Card Status Report—Provides card
order status. Cards are typically
received seven to 10 business days
after mail date.
•
Employee Listing—Provides a quick
overview of each employee's plan
listing, with details pertaining to
employee name, employee ID, current
account type, election amount,
available benefit plan balance, current
coverage start/end date, insurance,
and plan name.
•
Invoices—View past or current
invoices by clicking on the invoice date
to view invoice details. Items listed will
include invoice date, amount paid,
payment date, and description.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
•
Past/Pending Payments—Provides a
chronological listing of all prior
payments to HealthEquity for
contributions, deductions, and fees.
Employers can click on a payment date
to view the detailed invoice associated
with the payment. Elements of this
report include payment date,
contribution amount, deduction
amount, fees, total amount of
payment, descriptions of payment and
status.
•
Contribution History—View a listing
of each employee's contribution
history. The report displays total
contributions made by the employer to
employee’s HSAs. It also shows the
total contributions made by the
employee, excluding contributions
outside of payroll. With this report,
employers can click on an employee
name to see the date and amount of
each contribution
•
Held-up Contributions—View all
employer or employee contributions
being held for causes related to
customer identification process (CIP)
required by the USA PATRIOT Act,
contribution limits, etc. The report
includes employee ID, employee name,
amount contributed, reason for delay,
days waiting, reason, employer
contributions, and employee
contributions.
•
HSA Status—Provides employers with
information related to the date on
which employees were enrolled in an
HSA and whether they have taken
action to activate their account at
HealthEquity. Activation is defined as
having activated their HSA debit card,
logged into the account online and
accepted the terms of the online
agreement, or paid a claim. This report
also shows whether an employee's
HSA is closed.
•
Potential Over Contributions—
Details employees who received HSA
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
contributions that may be higher than
allowed based on their coverage type
and age for the tax year selected. Upon
notification, employees may contact
HealthEquity's member services team
to distribute the excess amount and
avoid IRS penalties.
•
Incentives—Tracks employees who
have reached an incentive by
employee and account type. This
report captures the employee name,
account, description of the earned
incentive, date completed, amount
posted and date the amount was
posted.
7.
Explain the payroll and transfer of funds process
from the employer to the bank.
BCBSAZ shares eligibility data with
HealthEquity on a nightly basis. The City, or
its support vendor, will work directly with
HealthEquity to determine the most
convenient method to share contribution
information, which is typically a data file
specifying individual employee contribution
accompanied by a single employer
automated clearinghouse (ACH), wire, or
check. Employers and members benefit
from HealthEquity’s proprietary web
capabilities featuring online payments and
real-time claims data, in addition to multiple
account access from a single portal.
Integration allows for a seamless experience
for the member, which means no toggling
between accounts to manage funds.
8.
Is a debit card available to plan participants?
Yes. HealthEquity provides a HealthEquity®
Visa® Health Account Card (debit card) for
HSAs and FSAs. Participants can receive up
to three debit cards at no additional charge.
These cards are Merchant Category Code
(MCC) restricted and limited to merchants
providing healthcare related products and
services, and can be used in a number of
ways, including but not limited to the
options listed below:
•
Swipe the card at a provider’ s office
just like a credit card
•
Link other personal bank accounts for
contributions and payments
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
•
Give a provider their card number over
the phone
•
Write the card number on a qualified
bill and send back to the provider
While the card can be used like a credit card
without the requirement of a PIN,
participants can set up a PIN on the account,
if desired.
9.
How many calendar days after receipt of
enrollment information is the debit card sent to
the participant?
Participants receive a welcome kit and debit
cards within 10 business days from the date
enrollment is complete.
10. Are you able to accept electronic enrollment
information? If not, in what format do you accept
enrollment information?
Yes. BCBSAZ automatically shares eligibility
data with HealthEquity as part of our
integrated partnership. The City will work
with HealthEquity to provide contributions
(both employer and employee dollars) as
separate file feeds either directly from the
City or through their payroll vendor.
HealthEquity can offer contribution file
integration for employers (groups with less
than 500 benefit eligible employees would
need to use a standardized format.).
Additionally, HealthEquity offers a
contribution tool available via the Employer
Portal, which will enable the City to input
contributions directly.
11. Are you able to open a participant’s account
using the City’s authorization only, rather than
requiring the participant to submit data?
No. Participants must complete the CIP
(Customer Identification Program)
requirements before an account can be
established. This is a requirement of the U.S.
Patriot Act and is required for all financial
institutions including HSA custodians.
HealthEquity uses LexisNexis Financial
Services to cross-check points of
identification for each participant. It will be
necessary to request data from some
individuals if they fail CIP. Less than 2
percent of individuals fail CIP and
HealthEquity will manage the request for
any required information and the City will
have access to on-demand reporting to see
the status of anyone pending completion of
the CIP process.
12. Can you set up eligibility guidelines specific for
temp employees and retirees (i.e. retirees pay
Yes, BCBSAZ can accommodate.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
their own admin fees, retirees and temps do not
receive debit cards)?
13. Please provide a demo link to your online
Website and/or Mobile App for the City to review.
HealthEquity’s website is HealthEquity.com
and their member portal can be accessed by
visiting MyHealthEquity.com.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
9.
REPORTING
Report Type
Month
Quarter
Annual
Vendor
Response
(Y or N)
Online
Access
(Y or N)
Excel
(Y or N)
Enrollment (subscriber/member)
by plan option, by coverage tier for
each employer
X
X
X
Y
Y
Y
Paid Claims
By Plan Option
X
X
X
Y
Y
Y
By Type (fee for service, capitated)
X*
X
X
Y
Y
Y
By Status (Active, COBRA, Retiree)
X
X
X
Y
Y
Y
By Member Cost-Sharing by Plan
Option
X
X
X
Y
Y
Y
Overpayments
X
N**
Y
Y
Large Claim Report - $50,000 with diagnosis
By Plan Option
X
X
X
Y
Y
Y
By Status (Active, Terminated,
COBRA)
X
X
X
Y
Y
Y
Other Claims Reports
Claims Lag
X
X
X
Y
Y
Y
Network Utilization
In-Network
X
X
X
Y
Y
Y
Out-of-network
X
X
X
Y
Y
Y
Out-of-State
X
X
X
Y
Y
Y
Utilization Management
Precertification
N
N
Case Management
X
Y
Y
Y
Large Claims Report including Case
Management Status
X
Y
Y
Y
Wellness Programs
Utilization
X
X
Y
N
Y
ROI Savings
X
Y
N
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
9.
REPORTING
Report Type
Month
Quarter
Annual
Vendor
Response
(Y or N)
Online
Access
(Y or N)
Excel
(Y or N)
Disease Management
Utilization Risk Stratification
(baseline and YTD)
X
X
N
Y
Clinical Goals Compliance
X
Y
N
Y
ROI Savings
X
Y
N
Y
Stop Loss Reports (for third party Stop Loss Vendor)
Identify when participants have
accumulated paid claims greater
than or equal to 50% of the specific
stop loss, including primary
diagnostic code.
X
Y
Provide Case Management Notes
for any open cases.
X
N
Provide pended claims.
X
N
Medical Utilization Benchmarks (City Industry Specific and Book of Business)
Client Industry Specific
X
X
X
Y
Y
Book of Business
X
X
X
Y
Y
Ad Hoc Reporting Capabilities
Ability for the City to generate Ad
Hoc Reports
Determined by the City***
Y
Y
Provide electronic eligibility and
health claims data for use in the
consultant’s data analytics
reporting system
X
Y
Y
Will the above information be
provided in a format to allow the
City or its Consultant to drill down
on the data?
Yes.
Notes:
* The only capitated services are chiropractic through our
partnership with ASH.
** BCBSAZ is willing to discuss.
*** BCBSAZ agrees to run up to 15 ad hoc (additional) reports for
the first contract year at no additional cost. Ad hoc reports, once
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
9.
REPORTING
Report Type
Month
Quarter
Annual
Vendor
Response
(Y or N)
Online
Access
(Y or N)
Excel
(Y or N)
agreed upon, will be provided to the group in up to 10 business
days.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
For the following categories, provide the
performance standard you are willing to
offer, the financial penalty (maximum dollar
amount or % of administrative fees) you will
agree to pay if the standard is not met, and
the method of measuring the penalty.
Measuremen
t Frequency
Dollars at Risk
(% or $)
1. Vendor attendance at City meetings
Quarterly
➢ Attendance by vendor representatives
when requested at meetings scheduled
by the City of Chandler during the
contract period and implementation
phase.
BCBSAZ Alternative Recommendation:
BCBSAZ proposes the Account Management
Performance Guarantee.
Standard: Overall score of 3 (satisfied) or
better on the BCBSAZ Account Management
Score Card (annual Group Benefit
Administrator survey) – see attached.
Desired Qualifiers: Categories include:
effective support for open enrollment events,
timely client notification of issues impacting
members, response to client issues and
questions in timely, comprehensive manner,
effective coordination to resolve open issues,
accessibility, and delivery of agreed-upon
reports on time.
Group specific
Measured
annually
2% of annual admin fee
2. Vendor call (or e-mail) return timeliness
Quarterly
➢ The City of Chandler or designated
consultant’s calls (or e-mails) to vendor
are returned within 48 business hours.
BCBSAZ Alternative Recommendation:
BCBSAZ proposes combining PGs 1 and 2
under the Account Management guarantee,
which guarantees ongoing communication
and support activities, including accessibility.
See #1
above.
See #1 above.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
3. Processing weekly eligibility updates
Weekly
➢ All updates to eligibility or enrollment
records will be made within three
business days after the information is
received by the vendor.
BCBSAZ Alternative Recommendation:
Standard: 99% of valid electronic eligibility
files are processed within five business days
of receipt of complete and accurate
information during initial implementation.
Group Specific
Measured
annually
2% of annual admin fee
4. Telephone call availability & answering
speed
Monthly
➢ 90% of all calls are answered within 30
seconds, and telephone service is
available between 8:00 am and 6:00 pm
Arizona Time Zone on business days.
BCBSAZ Alternative Recommendation:
Standard: BCBSAZ Customer Service calls
answered in an average of 45 seconds or
less.
Desired Qualifier: Average speed of answer
begins once the caller exits the IVR.1
Non-Group specific
Customer Service hours are 6 a.m. to 6 p.m.
(Arizona time), Monday through Friday.
Measured
quarterly
2% of annual admin fee
5. Telephone call on-hold (in-queue) time
Monthly
➢ An average of less than 2 minute(s) on
hold before a human being answers.
BCBSAZ Alternative Recommendation: This
guarantee is combined with PG #4
(telephone call availability and answering
speed).
See #4
above.
See #4 above.
6. Telephone Abandonment Rate
Monthly
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
➢ An abandonment rate of less than 3% is
maintained during standard business
hours.
BCBSAZ Alternative Recommendation:
Less than 5% of BCBSAZ Customer Service
calls abandoned. Desired Qualifier: Call
abandonment rate applies to calls
abandoned once the caller enters the call
queue.1
Non-Group specific
Measured
quarterly
2% of annual admin fee
7. Claims Processing Accuracy
Quarterly
➢ 99% of claims dollars submitted for
payment will be accurately processed and
paid. Regardless of whether or not these
standards of performance are satisfied,
the vendor must reimburse the City of
Chandler for all overpayments that are
not recovered from the recipient within
60 days after the overpayment is
discovered. The City of Chandler will
assign its right to recover such
overpayments to the vendor.
BCBSAZ Alternative Recommendation:
Standard: 98% of audited1 claims dollars are
paid in accordance with benefit plan designs
and in-force provider contracts.
Desired Qualifier: This penalty applies if
BCBSAZ fails to perform in accordance with
this standard two (2) consecutive reporting
periods. A penalty pay out of half of the fees
at-risk would occur for results at or below
97.5%.1
Non-Group specific
Measured
quarterly
2% of annual admin fee
8. Turnaround Time on Claims Payments
Quarterly
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10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
➢ 95% of all claims received will be
completely processed (paid, denied or
pended for additional information) within
14 calendar days after they are received.
100% of claims will be processed within
30 calendar days of receipt.
BCBSAZ Alternative Recommendation:
Standard: 90% of non-investigated clean
claims processed (paid or rejected) within 14
calendar days after receipt of clean claim.1
Desired Qualifier: A claim is defined as a
request for a payment of a plan benefit by a
plan participant or health care provider; a
claim is deemed received when it has been
time-stamped by BCBSAZ. Claims pended for
missing information or benefit eligibility will
be included as a documented claim. Non-
Group specific.
Claims processing penalties are not
applicable on claims incurred outside of
Arizona.
Measured
quarterly
2% of annual admin fee
9. Timeliness of Claim Reports
Annually
➢ Each report the vendor will supply the
City of Chandler will be provided within a
mutually agreed upon timeframe but no
later than the 10th of the month following.
BCBSAZ Alternative Recommendation:
Standard: Monthly standard reports will be
delivered on time.
Desired Qualifier: Delivery of standard
reports: whYzen-BlueInsightSM, our self-serve
online reporting tool is available online, and
updated the 20th of the month.
Group specific
Measured
annually
2% of annual admin fee
10. Claims Coding
Annually
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10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
➢ 98% of all claims will be coded with no
errors.
BCBSAZ Alternative Recommendation:
Standard: 95% of audited claims are
processed in accordance with benefit plan
designs.1
Desired Qualifier: Percentage of claims
processed incorrectly vs. correctly, based on
BCBSAZ standard auditing procedures.
Non-Group specific
Measured
quarterly
2% of annual admin fee
11. Implementation (if appropriate)
Annually
➢ Successful implementation as defined by
key milestones. Include measurable
milestones in your proposal.
BCBSAZ Alternative Response: Standard:
BCBSAZ will complete a successful
implementation as defined by key
milestones.
Desired Qualifier: BCBSAZ agrees to meet
milestones as outlined on the proposed
implementation timeline (See Section 5U).
Note: the current proposed implementation
timeline will be agreed upon and finalized
during initial implementation meetings.
Group specific
Measured 90
days after
effective
date and
paid out 120
days after
effective
date.
2% of annual admin fee
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10.
PERFORMANCE GUARANTEES
(ALL PROPOSERS)
VENDOR RESPONSE
12. Data Exchange
Annually
➢ Receive and transmit data with vendors
based on a frequency defined by the
business needs of the City of Chandler.
BCBSAZ Alternative Response: Standard:
BCBSAZ will receive and transmit data with
vendors based on a frequency defined by the
business needs of Client.
Desired Qualifier: Should BCBSAZ interface
with any independent vendors to service
client, we agree to establish appropriate
mutually agreeable performance standards
for data transmission.
TBD
TBD
2% of annual admin fee
Total of all risk measures cannot exceed 20% (based on administrative fee only).
1 If BCBSAZ fails to perform in accordance with these guarantee(s) for two (2) consecutive reporting
periods after the guarantee(s) are effective, BCBSAZ will refund or credit the group up to the amount
at risk per measure during the time period which BCBSAZ did not meet the performance guarantee(s).
Additional BCBSAZ Notes:
1. The above stated performance guarantees will be effective for a one year period 1/1/2023 to
12/31/2023., and will be assessed on an annual basis.
2. The performance guarantee payout does not include stop loss premiums, claims reimbursement
amounts, vendor interface fees, capitated claim payments, etc.
3. Performance guarantees are reported to the client approximately 90 days after the close of the
measurement period or plan year. Payout is made (if applicable) after the reporting of results.
4. BCBSAZ will not be required to pay a penalty for performance guarantees if the group is in default
of its contract with BCBSAZ and/or has not paid all claims and premiums by the date due.
5. BCBSAZ will determine the sample size of audited claims.
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Exhibit A 3
BCBSAZ Services Included in Administrative Fees
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Exhibit A 4
BCBSAZ Subcontractor List
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Exhibit A 5
BCBSAZ Proposed Implementation Timeline
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Exhibit A 6
BCBSAZ Specialty Drug List
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Exhibit A 7
BCBSAZ Audit Requirements
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Exhibit A 8
Pharmacy Claims Excluded from Guarantees
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Exhibit B
Compensation and Fees
Begins on next page.
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Exhibit B 1
Medical Worksheet City of Chandler BAFO
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Exhibit B 2
RX Worksheet City of Chandler BAFO
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Exhibit B 3
City of Chandler Renewal Rates and Assumptions
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Exhibit B 4
Pharmacy Pricing Grid Pass Through 2023
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Exhibit B 5
HSA Employer and Account Holder Fees
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Exhibit C
Insurance Requirements
INSURANCE
General.
A.
At the same time as execution of this Agreement, the Contractor shall furnish the City a
certificate of insurance on a standard insurance industry ACORD form. The ACORD form
must be issued by an insurance company authorized to transact business in the State of
Arizona possessing a current A.M. Best, Inc. rating of A-7, or better and legally authorized
to do business in the State of Arizona with policies and forms satisfactory to City.
Provided, however, the A.M. Best rating requirement shall not be deemed to apply to
required Workers’ Compensation coverage.
B.
The Contractor and any of its subcontractors shall procure and maintain, until all of their
obligations have been discharged, including any warranty periods under this Agreement
are satisfied, the insurances set forth below.
C.
The insurance requirements set forth below are minimum requirements for this
Agreement and in no way limit the indemnity covenants contained in this Agreement.
D.
The City in no way warrants that the minimum insurance limits contained in this
Agreement are sufficient to protect Contractor from liabilities that might arise out of the
performance of the Agreement services under this Agreement by Contractor, its agents,
representatives, employees, subcontractors, and the Contractor is free to purchase any
additional insurance as may be determined necessary.
E.
Failure to demand evidence of full compliance with the insurance requirements in this
Agreement or failure to identify any insurance deficiency will not relieve the Contractor
from, nor will it be considered a waiver of its obligation to maintain the required
insurance at all times during the performance of this Agreement.
F.
Use of Subcontractors: If any work is subcontracted in any way, the Contractor shall
execute a written contract with Subcontractor containing the same Indemnification
Clause and Insurance Requirements as the City requires of the Contractor in this
Agreement. The Contractor is responsible for executing the Agreement with the
Subcontractor and obtaining Certificates of Insurance and verifying the insurance
requirements.
Minimum Scope and Limits of Insurance. The Contractor shall provide coverage with limits of liability
not less than those stated below.
A.
Commercial General Liability-Occurrence Form. Contractor must maintain “occurrence”
form Commercial General Liability insurance with a limit of not less than $2,000,000 for
each occurrence, $4,000,000 aggregate. Said insurance must also include coverage for
products and completed operations, independent contractors, personal injury and
advertising injury. If any Excess insurance is utilized to fulfill the requirements of this
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paragraph, the Excess insurance must be “follow form” equal or broader in coverage
scope than underlying insurance.
B.
Automobile Liability-Any Auto or Owned, Hired and Non-Owned Vehicles
Vehicle Liability: Contractor must maintain Business/Automobile Liability insurance with
a limit of $1,000,000 each accident on Contractor owned, hired, and non-owned vehicles
assigned to or used in the performance of the Contractor’s work or services under this
Agreement. If any Excess or Umbrella insurance is utilized to fulfill the requirements of
this paragraph, the Excess or Umbrella insurance must be “follow form” equal or broader
in coverage scope than underlying insurance.
C.
Workers Compensation and Employers Liability Insurance: Contractor must maintain
Workers Compensation insurance to cover obligations imposed by federal and state
statutes having jurisdiction of Contractor employees engaged in the performance of work
or services under this Agreement and must also maintain Employers’ Liability insurance
of not less than $1,000,000 for each accident and $1,000,000 disease for each employee.
D.
Technology Errors and Omissions Liability including Network Security and Privacy Liability
For Contracts under $500,000
Minimum Limits:
Per Loss
$ 3,000,000
Aggregate
$ 3,000,000
For Service Contracts over $500,001
Minimum Limits:
Per Loss
$ 5,000,000
Aggregate
$ 5,000,000
The policy shall cover professional misconduct or lack of ordinary skill for those positions
defined in the Scope of Services of this contract.
In the event that the professional liability insurance required by this Contract is written
on a claims-made basis, Contractor warrants that any retroactive date under the policy
shall precede the effective date of this Contract; and that either continuous coverage will
be maintained or an extended discovery period will be exercised for a period of two years
beginning at the time work under this Contract is completed.
If such insurance is maintained on an occurrence form basis, Contractor shall maintain
such insurance for an additional period of one year following termination of Contract. If
such insurance is maintained on a claims-made basis, Contractor shall maintain such
insurance for an additional period of three years following termination of the Contract.
If Contractor contends that any of the insurance it maintains pursuant to other sections
of this clause satisfies this requirement (or otherwise insures the risks described in this
section), then Contractor shall provide proof of same.
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The insurance shall provide coverage for the following risks
a. Liability arising from theft, dissemination and / or use of confidential information (a
defined term including but not limited to bank account, credit card account, personal
information such as name, address, social security numbers, etc. information) stored
or transmitted in electronic form
b. Network Security Liability arising from the unauthorized access to, use of or tampering
with computer systems including hacker attacks, inability of an authorized third party,
to gain access to your services including denial of service, unless caused by a
mechanical or electrical failure
c. Liability arising from the introduction of a computer virus into, or otherwise causing
damage to, a customer’s or third person’s computer, computer system, network or
similar computer related property and the data, software, and programs thereon.
Additional Requirements:
a. The policy shall provide a waiver of subrogation
Additional Policy Provisions Required.
A. Self-Insured Retentions or Deductibles. Any self-insured retentions and deductibles must be
declared and approved by the City. If not approved, the City may require that the insurer
reduce or eliminate any deductible or self-insured retentions with respect to the City, its
officers, officials, agents, employees, and volunteers.
1. The Contractor’s insurance must contain broad form contractual liability coverage.
2. The Contractor's insurance coverage must be primary insurance with respect to the
City, its officers, officials, agents, and employees. Any insurance or self-insurance
maintained by the City, its officers, officials, agents, and employees shall be in excess
of the coverage provided by the Contractor and must not contribute to it.
3. The Contractor's insurance must apply separately to each insured against whom
claim is made or suit is brought, except with respect to the limits of the insurer's
liability.
4. Coverage provided by the Contractor must not be limited to the liability assumed
under the indemnification provisions of this Agreement.
5. The policies must contain a severability of interest clause and waiver of subrogation
against the City, its officers, officials, agents, and employees, for losses arising from
Work performed by the Contractor for the City.
6. The Contractor, its successors and or assigns, are required to maintain Commercial
General Liability insurance as specified in this Agreement for a minimum period of
three years following completion and acceptance of the Work. The Contractor must
submit a Certificate of Insurance evidencing Commercial General Liability insurance
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during this three year period containing all the Agreement insurance requirements,
including naming the City of Chandler, its agents, representatives, officers, directors,
officials and employees as Additional Insured as required.
7. If a Certificate of Insurance is submitted as verification of coverage, the City will
reasonably rely upon the Certificate of Insurance as evidence of coverage but this
acceptance and reliance will not waive or alter in any way the insurance requirements
or obligations of this Agreement.
B.
Insurance Cancellation During Term of Contract/Agreement.
1. If any of the required policies expire during the life of this Contract/Agreement, the
Contractor must forward renewal or replacement Certificates to the City within ten
days after the renewal date containing all the required insurance provisions.
2. Each
insurance
policy
required
by
the
insurance
provisions
of
this
Contract/Agreement shall provide the required coverage and shall not be suspended,
voided or canceled except after 30 days prior written notice has been given to the
City, except when cancellation is for non-payment of premium, then ten days prior
notice may be given. Such notice shall be sent directly to Chandler Law-Risk
Management Department, Post Office Box 4008, Mailstop 628, Chandler, Arizona
85225. If any insurance company refuses to provide the required notice, the
Contractor or its insurance broker shall notify the City of any cancellation, suspension,
non-renewal of any insurance within seven days of receipt of insurers’ notification to
that effect.
A.
City as Additional Insured. The policies are to contain, or be endorsed to contain, the
following provisions:
1. The Commercial General Liability and Automobile Liability policies are to contain, or
be endorsed to contain, the following provisions: The City, its officers, officials,
agents, and employees are additional insureds with respect to liability arising out of
activities performed by, or on behalf of, the Contractor including the City's general
supervision of the Contractor; Products and Completed operations of the Contractor;
and automobiles owned, leased, hired, or borrowed by the Contractor.
2. The City, its officers, officials, agents, and employees must be additional insureds to
the full limits of liability purchased by the Contractor even if those limits of liability
are in excess of those required by this Agreement.
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Exhibit D
Special Conditions
NONE
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Exhibit E
BCBSAZ Stop Loss Agreement
Group Contract Number 028399
PARTIES: Blue Cross and Blue Shield of Arizona, Inc. ("BCBSAZ"), an Arizona non-profit corporation
and an independent licensee of the Blue Cross and Blue Shield Association, and City of Chandler
(the “Contract holder”), headquartered in Arizona.
EFFECTIVE DATE: January 1, 2023
SCOPE:
Medical Only
X Medical and Pharmacy
If there are any inconsistencies between this Agreement and any prior stop loss agreements or the
Administrative Services Agreement between BCBSAZ and Contract holder, the terms and
conditions of this Agreement shall control.
In consideration of the promises and the mutual covenants contained in this Agreement, BCBSAZ
and Contract holder (the “Party” or “Parties” as appropriate) agree as follows:
ARTICLE I - DEFINITIONS
For purposes of this Agreement and any amendments, attachments, or schedules to this
Agreement, the following words and terms have the following meanings unless the context or use
clearly indicates another meaning or intent. If a term is not defined, the term shall have the
same meaning as defined in the Administrative Services Agreement between the Parties.
Administrative Services Agreement (ASA): The Administrative Service Agreement entered
into by BCBSAZ and Contract holder pursuant to which BCBSAZ provides administrative services
to the Contract holder’s Plan.
Aggregate Corridor: A specific percentage above expected claims which is set forth in the ASA.
Aggregate Stop Loss Maximum: The total amount of Payments for Covered Services beyond
which Payments for Covered Services again become the financial responsibility of the Contract
holder and are not the financial responsibility of BCBSAZ. Any Aggregate Stop Loss Maximum
will be set forth in the ASA.
Aggregating Deductible: A one-time annual, additional amount of Payments for Covered Services
which must be satisfied by Contract holder after meeting its Specific Stop Loss Limit and before
BCBSAZ is obligated to make any specific stop loss coverage payment under this Stop Loss
Agreement. Any Aggregating Deductible will be set forth in the ASA. Only Payments for Covered
Services in excess of the Specific Stop Loss Limit apply to meeting the Aggregating Deductible.
Aggregate Stop Loss Limit (ASL): The total dollar amount of Payments for Covered Services for
which Contract holder is financially responsible. BCBSAZ is financially responsible for Payments
X
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for Covered Services in excess of the ASL according to the terms of this Agreement. For any
Contract Month, the ASL shall be the greater of: (1) the Minimum Monthly Attachment Level set
forth in the ASA, or (2) the product of Enrollment and ICAP Rates.
Contract Month: A calendar month within the Contract Period.
Contract Period: The term of this Stop Loss Agreement.
Covered Services: Health care services and supplies, as referenced in the scope section of this
Stop Loss Agreement, rendered or delivered to Participants for which benefits are available under
the Plan.
Eligible Claim Date Period. The dates during which claims for benefits provided under the terms
of the Plan must be Incurred and paid in order to be covered by this Agreement.
Eligible Participants or Participants: Collectively Employees and Dependents as defined in the
Plan(s) and as designated by class and coverage in the employer application.
Enrollment Units and Enrollment Categories/Tiers: Enrollment Unit shall mean each employee,
with or without dependents, enrolled for coverage under the respective Plan(s). Enrollment Units
are categorized for rating purposes into Enrollment Categories. Enrollment Categories/Tiers are
based upon whether the employee only or the employee and dependents are enrolled. In
addition, Enrollment Categories may distinguish which dependents are enrolled along with the
employee. For example: employee and spouse; employee and child(ren); employee and
dependent(s) (spouse and/or child(ren). Premiums and/or other cost factors are based on
Enrollment Categories/Tiers.
Incurred: The date on which a supply is obtained or a service is rendered to a Participant.
Incurred Claims Attachment Point (ICAP) Rates: Expected incurred claims by Enrollment
Category times the Aggregate Corridor.
Excluded Participants: Specific Participants who are either excluded entirely from this Stop Loss
Agreement or who may be subject to a different Specific Stop Loss. If this applies, it will be
reflected in the ASA.
Plan: Shall mean only that portion of the self-funded employee welfare benefit plan that provides
for medical or medical and pharmacy benefits, as described in the scope section of this Stop Loss
Agreement and as expressly set forth in the Contract holder’s Benefit Plan Booklet attached to the
Contract holder’s ASA and administered by BCBSAZ and which is incorporated herein by reference.
Run-In Coverage: If run-in coverage applies to this Stop Loss Agreement it will be reflected in the
ASA. Run-in Coverage applies to claims incurred within a specified period prior to the Effective
Date of this Stop Loss Agreement, processed by a third party administrator other than BCBSAZ
and paid by Contract holder within a specified period after the Effective Date of this Stop Loss
Agreement and under the terms of a valid plan. The Run-In Coverage period will be expressed in
the ASA as a number of months prior to the effective date of this Stop Loss Agreement in which the
claims must be incurred and the number of months after the effective date of this Stop Loss
Agreement in which claims must have been paid.
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Run-Out Claims: Those claims for Covered Services that are incurred but unreported and/or
unpaid as of the date this Agreement terminates and paid within the Run-Out Period.
Run-Out Period: Unless otherwise noted in the ASA, the Run-Out Period is twelve (12) months after
the date of termination of this Stop Loss Agreement.
Specific Stop Loss Limit (SSL): The limitation of Contract holder’s liability for payment for
Covered Services for an Eligible Participant. The Specific Stop Loss Limit is set forth in the ASA.
Specific Stop Loss Maximum: The total dollar amount of Payments for Covered Services beyond
which Payments for Covered Services for a Participant again become the financial responsibility of
the Contract holder and are not the financial responsibility of BCBSAZ. The Specific Stop Loss
Maximum is set forth in the ASA.
ARTICLE II -- REIMBURSEMENT
1.
Reimbursement. BCBSAZ agrees to credit Contract holder as follows.
a.
Aggregate: If Aggregate Stop Loss applies, BCBSAZ will credit Contract holder,
subject to the terms and conditions of this Agreement and any applicable Aggregate
Stop Loss Maximum reflected in the ASA, if Contract holder’s Payments for Covered
Services for Eligible Participants for the applicable Contract Period exceed the ASL.
b.
Specific: If Specific Stop Loss applies, BCBSAZ will credit Contract holder, subject
to the terms and conditions of this Agreement and any applicable Specific Stop
Loss Maximum reflected in the ASA, if Contract holder’s Payments for Covered
Services for a specific Eligible Participant exceed the SSL and the Aggregating
Deductible. In the event that the Specific Stop Loss Limit is reached, no amount in
excess of the Specific Stop Loss Limit shall be applied towards attainment of any
Aggregate Stop Loss Limit.
Certain payments may be excluded from the aggregate and specific stop loss coverage
provided in this Agreement. These exclusions are set forth in Section 4 below. In addition,
the calculation and payment of any reimbursement amounts is subject to the limitations
on coverage and other conditions set forth in this Agreement.
2.
Run-In Coverage. inclusion of Run-In Coverage claims in the calculation of the Contract
holder’s ASL and SSL is conditioned upon Contract holder providing BCBSAZ, by the first
day of each month, an Excel report of the claims which were incurred within the specified
period but not paid by or on behalf of Contract holder prior to the effective date of this
Stop Loss Agreement. The report shall include the following fields: employee Social
Security Number, employee first and last name, patient first and last name, patient date of
birth, incurred dates of service, paid date, paid amount. Any claims report received after
the first day of the month will be allocated to the following month’s reimbursement
calculation. Contract holder is solely responsible for the costs of any reports that are
required to validate run-in claim amounts.
3.
Application of Payments for Covered Services; Run-Out Coverage. Payments for
Covered Services incurred within a Contract Year and paid within that Contract Year or
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within twelve (12) months following the close of that Contract Year shall be considered to
be incurred during that Contract Year. Payments for Covered Services incurred during
the Contract Year but paid more than twelve (12) months after the close of that Contract
Year shall be considered to be incurred in the subsequent Contract Year. If there is no
subsequent Contract Year, then Payments for Covered Services incurred within the final
Contract Year and paid within the Run-Out Period shall be considered to be incurred during
the final Contract Year. Payments that are incurred in one Contract Year will not count
towards attainment of any stop loss limits under a subsequent Contract Year.
4.
Payments Excluded from Contract holder's ASL and SSL: The following payments are
excluded from coverage under this Agreement and will not be applied to Contract
holder’s ASL and/or SSL:
a.
Any payments for persons other than Eligible Participants or payments for Eligible
Participants for services that are not Covered Services or otherwise outside of the
terms and conditions of Contract holder’s Plan as described in the Plan’s Summary
Plan Description, including but not limited to claims that are covered by another
contract;
b.
Payments made by the Contract holder for an individual who is an Excluded
Participant, excluding them from the Stop Loss Agreement.
c.
Payments made by the Contract holder for which there has been or will be
reimbursement by any other third party (including amounts described in Article
II.11 below);
d.
Payments Incurred after the termination of this Agreement;
e.
Payments for which BCBSAZ has otherwise reimbursed the Contract holder.
5.
Monthly Enrollment Units. Monthly Enrollment Units maybe retroactively adjusted (up
to 12 months after the reporting month) to reflect the appropriate enrollment within each
Enrollment Category. Retroactive adjustments include, but are not limited to, additions and
terminations reported to BCBSAZ subsequent to any reporting month.
6.
Claims Processed by Other Benefit Administrators. If an entity other than BCBSAZ
is acting as a benefit administrator, Contract holder, or the Benefit Administrator, must
submit a claim for reimbursement to BCBSAZ by the earlier of: (a) ninety (90) days after the
date of service; or (b) thirty (30) days after the date the health care provider submits the
claim to the Contract holder or Benefit Administrator. Notwithstanding the foregoing,
BCBSAZ shall have no liability to pay or reimburse for any claim submitted to BCBSAZ by
Contract holder or Benefit Administrator later than one (1) year after the effective date of
termination of this Agreement. Contract holder, or the Benefit Administrator, must provide
BCBSAZ with such information BCBSAZ may reasonably request to support such claim,
including proof of payment.
7.
Determination. BCBSAZ shall make a determination as to the validity of a claim for
reimbursement under this Stop Loss Agreement within thirty (30) days of receipt of such
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claim.
8.
Reconsideration. Upon written request, BCBSAZ may reconsider its original
determination. A written request for reconsideration must be filed with BCBSAZ within sixty
(60) days following the date the first disallowance or payment notice is mailed. Additional
documentation in support thereof must accompany the request, if appropriate. Failure to
timely request reconsideration shall waive the Contract holder's right to reconsideration
under this Agreement. BCBSAZ will review the request for reconsideration and will notify
Contract holder, or the Benefit Administrator, as the case may be, of its decision in writing
within sixty (60) days following receipt of the request for reconsideration.
9.
Contested Claims. Where any payment is approved in relation to a contested claim,
BCBSAZ shall determine, on the basis of the date on which payment is actually made,
whether such payment or any portion of it is an obligation of the Contract holder or an
obligation of BCBSAZ under the terms of this Agreement. Benefit payments made in
accordance with the terms of any judgment or settlement shall be considered benefits
paid to Eligible Participants under the Plan during the period in which such judgment or
settlement is satisfied, whether paid during the term of this Agreement or following the
termination of this Agreement.
10.
Subrogation. If Contract holder receives any reimbursement from any third party for
payment for Covered Services, BCBSAZ shall be entitled to recover such amounts to the
extent that BCBSAZ has reimbursed the Contract holder for those regardless of whether
or not such reimbursement is received during the year in which the respective payments
are incurred and whether or not such reimbursement is received during the term of
this Agreement or after the termination of this Agreement. Contract holder agrees to
cooperate to assure BCBSAZ's right to recover.
ARTICLE III – STOP LOSS PREMIUMS
1.
Premium Payments. Contract holder shall pay BCBSAZ such premiums and other fees,
taxes and charges (“Fees and Charges”) as set forth in ASA. BCBSAZ will invoice the Contract
holder for such Fees and Charges which are due and payable on the first (1st) day of each
calendar month or as otherwise stated in the BCBSAZ invoice. Any amounts not timely
paid within the applicable time period shall accrue interest at the rate of one percent (1%)
per month until paid in full.
2.
Grace Period. This Stop Loss Agreement has a grace period of thirty-one (31) days. During
the grace period, the Stop Loss Agreement shall remain in force provided that the premium
is paid before the end of the grace period. If, by the last day of the applicable grace period,
Contract holder fails to pay the premiums which are due, the Stop Loss Agreement will
terminate without further notice as of midnight on the last day for which premiums were
paid and Run-Out Coverage, if any, will not apply. In such case, Contract holder shall be
liable for all Covered Services rendered to Eligible Participants during and after the grace
period, and the Contract holder agrees to hold BCBSAZ harmless from all costs therefor.
3.
Rate Changes: Additionally, BCBSAZ may change Contract holder’s premium or premium
rates upon the occurrence of one or more of the following events:
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a.
A modification of the terms of this Agreement; or
b.
As of the date BCBSAZ accepts modifications to Contract holder’s Plan; or
c.
A change in Contract holder’s contribution (percentage or dollar amount); or
d.
A change in the total number of Participants resulting in either an increase or
decrease of 10% or more of the number of Participants that were enrolled for
coverage on the date the stop loss premium was last modified; or
e.
If federal or state law affecting premium payments, benefits, administrative
procedures, or other aspects of this Agreement are amended. The effective date
of such change shall depend upon the nature of the change in law; or
f.
As otherwise specifically stated in this Agreement.
4.
Taxes. BCBSAZ specifically reserves the right to recover from Contract holder any
premium tax deficiencies, which may be assessed against BCBSAZ with respect to prior
periods of coverage under this Agreement, whether such deficiencies are assessed during
the term of this Agreement or following its termination.
5.
Self-Insured Plan Status. This Agreement shall in no event be construed in a manner to alter
the fact that Contract holder’s Plan is a self-insured plan and, as such, is not subject to the
state insurance laws or regulations, due to the application of Section 514(a) of ERISA. Any
payments made under this Agreement shall only be for the benefit of Contract holder.
BCBSAZ has no obligation or liability under this Agreement to provide benefits to Eligible
Participants. No Eligible Participant shall have the right to any of the proceeds of any stop
loss insurance obtained by Contract holder pursuant to this Agreement.
ARTICLE IV- CONTRIBUTION; PARTICIPATION
1.
Contract holder agrees to contribute at least seventy-five percent (75%) of the cost for all
Eligible Participants for employee only coverage and fifty percent (50%) of the total cost for
all Eligible Participants for family coverage.
2.
If Contract holder contributes one hundred percent (100%) of the cost for Eligible
Participants, all employees eligible for coverage under the Plan and this Agreement must
be enrolled.
3.
If Contract holder contributes less than one hundred percent (100%) of the cost for Eligible
Participants, at least seventy-five percent (75%) of all employees eligible for coverage
under the Plan and this Agreement must be enrolled. Those employees eligible for
coverage under the Plan and this Agreement who are covered under their spouse’s group
health plan, Medicare, Arizona Health Care Cost Containment System (AHCCCS), Tricare or
Indian Health Services shall not be considered for purposes of determining whether
Contract holder has satisfied this seventy-five percent (75%) requirement. In any event, at
least one hundred (100) Eligible Participants must be enrolled on the effective date of this
Agreement.
4.
Contract holder agrees to comply with such other contribution and participation
requirements as shall be mutually agreed upon by the Parties from time to time. Such
requirements shall become effective no sooner than sixty (60) days after BCBSAZ has given
written notice to the Contract holder.
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ARTICLE V- RENEWAL AND TERMINATION
1.
Term; Renewal. The Term of this Stop Loss Agreement shall match the term of the
ASA. If Contract holder desires, and BCBSAZ is willing, to renew this Stop Loss Agreement
at time of renewal of the ASA, the parties shall execute an ASA Amendment which will set
forth renewal terms for both the ASA and this Stop Loss Agreement. If Stop Loss terms are
not included in an ASA Amendment, this Stop Loss Agreement shall terminate at the end
of the immediate Term.
2.
Termination. This Agreement may be terminated as follows:
a.
Either Party may terminate this Agreement at any time in the event of a material
breach of this Agreement by the other, but only if said breach is not cured within
thirty (30) days after written notice to the breaching Party.
b.
BCBSAZ may terminate this Agreement upon the occurrence of any of the following:
i.
Failure by the Contract holder to pay when due the Fees and Charges.
ii.
Upon five (5) days’ prior written notice of failure by the Contract holder to
provide funds necessary to satisfy its liability for Payments made for Covered
Services, as provided in the Contract holder’s ASA.
iii.
The sale, exchange or transfer of: (i) all or substantially all of the assets of
Contract holder to a third party, (ii) more than twenty-five percent (25%) of
the outstanding stock in Contract holder, or (iii) controlling interest in
Contract holder, whichever is less.
iv.
Insolvency, appointment of a receiver or a trustee for Contract holder,
assignment for the benefit of creditors by Contract holder, or the
commencement of any proceedings under bankruptcy or insolvency laws
by or against Contract holder that continues for sixty (60) days, or the
attachment, levy or other seizure by legal process of any substantial part of
the assets of Contract holder, and such attachment, levy or seizure is not
quashed, stayed or released within sixty (60) days of its occurrence.
v.
Default by Contract holder under any other agreement with BCBSAZ.
vi.
Fraud or misrepresentation by the Contract holder. In the event of fraud or
misrepresentation by Contract holder, BCBSAZ also shall have the rights set
forth in Article VI.4.
vii. Changes to the Plan which are not acceptable to BCBSAZ.
c.
This Agreement will terminate automatically upon the occurrence of any of the
following:
i.
Termination of the Plan in its entirety.
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ii.
The enactment of any law or the promulgation of any regulation that makes
it illegal to continue this Agreement or for BCBSAZ to perform any of the
services required under this Agreement.
iii.
The termination of the Contract holder’s ASA.
d.
After this Agreement has been in effect for twelve (12) months, either Party may
terminate this Agreement at any time, without cause, as of the last day of any
calendar month by giving thirty (30) days’ prior written notice to the other Party.
e.
Upon termination of this Agreement, the Parties shall have only those continuing
duties of performance as provided herein; except that, upon completion of its
performance under this Agreement, BCBSAZ shall cause the orderly transfer of
records, if any, from BCBSAZ to the Contract holder or its designee in a time frame
mutually agreed upon, but not to exceed six (6) months from the date of
termination.
The Contract holder agrees to reimburse BCBSAZ for any and all amounts BCBSAZ
is required to pay pursuant to an applicable grievance and/or appeals process
regardless of whether BCBSAZ is still administering claims for the Contract holder at
the time the appeal is conducted. The Contract holder also agrees to reimburse
BCBSAZ for any and all amounts which the Centers for Medicare & Medicaid Services
(CMS) or any other government agency requires BCBSAZ to pay because Medicare
was not required to pay as primary, regardless of whether BCBSAZ is administering
claims for the Contract holder at the time CMS makes such determination.
If the term of this Agreement is less than twelve (12) months, the Contract holder’s
ASL and SSL will be annualized to reflect a complete twelve (12) month contract year.
ARTICLE VI - GENERAL PROVISIONS
1.
Records and Review. Contract holder will maintain appropriate records demonstrating
its compliance with the requirements of this Stop Loss Agreement and which may be
necessary to determine when Contract holder’s ASL and SSL have been satisfied. Contract
holder agrees to furnish these records to BCBSAZ upon request.
2.
Audit. Upon reasonable prior written notice, BCBSAZ shall have the right to inspect and
audit all records and procedures of Contractor and, if applicable, Benefits
Administrator, that are applicable to the administration of this Agreement.
3.
Modifications to Plan. Contract holder shall notify BCBSAZ immediately regarding any
modification of the Plan(s), as described in the Contract holder’s Summary Plan
Description, that impact this Agreement, or of the termination of the Plan. No
modification shall be binding upon BCBSAZ until accepted by BCBSAZ in writing.
4.
Misrepresentation; Concealment; Omission. BCBSAZ has relied on information
provided by Contract holder in entering into this Agreement. In the event of any
misrepresentation, concealment or omission, intentional or not, which materially affects
the underwriting, premium or terms of this Agreement, BCBSAZ may: (i) retroactively
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modify the terms of the Agreement, including, without limitation, increasing premium
rates, SSL and ASL, or (ii) terminate this Agreement. If Contract holder willfully or
intentionally misrepresented or omitted material information, BCBSAZ may elect to declare
this Stop Loss Agreement null and void.
5.
Indemnification. Each Party shall indemnify, hold harmless and defend the other Party,
its directors, officers, elected officials, employees, or agents from and against any and all
actions, causes of action, suits, judgments, settlements, claims, losses, damages, liabilities,
penalties, costs, and/or expenses arising out of or resulting from its own breach of this
Stop Loss Agreement or negligent acts or omissions with respect to its obligations under
the terms of this Stop Loss Agreement.
6.
Legal Action. Contract holder agrees that it shall not file suit until sixty (60) days after
the date upon which the Contract holder, or the Benefit Administrator, submits proof of
claim and satisfaction of applicable ASL and SSL as required under this Agreement.
Contract holder cannot file suit more than three (3) years after the date on which it must
give BCBSAZ proof of loss.
7.
Legal Fees. Notwithstanding any provision of A.R.S. section 12-341.01, in any action to
enforce the terms of this Agreement, the successful party, defined as the net winner
considering all claims and counterclaims actually adjudicated, shall be entitled to an award
of its reasonable attorneys’ fees and costs. The award of reasonable attorney fees shall be
made to mitigate the burden of the expense of litigation to establish a just claim or a just
defense. It need not equal or relate to the attorney fees actually paid or contracted, but
the award may not exceed the amount paid or agreed to be paid. In a judicial action, any
award of fees shall be made by the court and not by a jury.
8.
Offset. BCBSAZ may offset payments due to Contract holder under this Agreement against
claims overpayments, unpaid premiums or other amounts owed by Contract holder.
9.
Confidentiality. Contract holder shall, and shall cause its principals and agents, (including,
but not limited to, the Benefit Administrator), to maintain the confidentiality of all
proprietary information with respect to BCBSAZ acquired during the term of this
Agreement. Such proprietary information shall not be divulged, disclosed or otherwise
made available to anyone not a Party to this Agreement without BCBSAZ's prior written
consent, nor shall such proprietary information be used to the detriment of BCBSAZ.
10.
Governing Law; Venue; Arbitration. The laws of the United States and the State of
Arizona (without regard to conflict of law provisions) govern all matters relating to this
Agreement. The federal or state courts located in Phoenix, Arizona, are the exclusive
venue for resolution of any dispute, controversy or claim arising out of or relating to this
Agreement, and the parties consent to the exclusive jurisdiction and venue of such courts.
Provided however, BCBSAZ, in its sole discretion, may elect to submit this matter to
binding arbitration before a single arbitrator in accordance with the American Health
Lawyer Association's Commercial Rules of Procedure.
11.
Prevailing Terms. During the term of this Agreement, in the event that the terms of this
Agreement are inconsistent with the terms of the respective Plan(s), as described in the
Contract holder’s Summary Plan Description, the terms of this Agreement shall prevail.
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12.
Waiver; Severability. No failure or delay by either party in exercising any right, power or
remedy under this Agreement, except as specifically provided herein, will be deemed as a
waiver of any such right, power, or remedy. If any provision of this Agreement is held by a
court of competent jurisdiction to be invalid or unenforceable, the remaining provisions of
this Agreement will remain in full force and effect if the essential provisions of this
Agreement for each party remain valid, legal, and enforceable.
13.
Notices. Any notices permitted or required to be given under this Agreement must be in
writing and will be deemed validly given upon delivery if: (a) personally delivered with
service fees prepaid, or (b) delivered with fees prepaid by reputable overnight courier that
provides proof of delivery. All notices to a Party will be sent to its address set forth in the
ASA, or to another address as may be designated by written notice to the sending Party.
Notice to the Broker/Agent/Consultant designated in the Administrative Services
Agreement shall constitute notice to the Contract holder.
14.
Use of Tradename. Each Party expressly agrees not to use the corporate name or any
tradename, trademark or service mark of the other Party in any advertising, publications,
press releases, brochures or other public communications without the prior written
consent of the other Party.
15.
Entire Agreement. The entire agreement between Contract holder and BCBSAZ shall
consist of this Stop Loss Agreement, the ASA and any ASA Amendment. No other
promises, terms, conditions or representations will be valid or binding.
16.
Amendment. Except as otherwise specifically provided under this Agreement, this
Agreement may be altered, amended or modified only in writing upon the mutual written
consent of the Parties. BCBSAZ, however, specifically reserves the right to alter, amend or
modify this Agreement and/or its performance under this Agreement: (i) as may be
required by applicable state and/or federal law; (ii) as may be necessitated by the terms
and conditions of various participation agreements with Providers; and (iii) upon the
occurrence of an event described in Article III, Paragraph 3.
17.
Assignment. Contract holder may not assign its rights or interest in this Agreement to any
other party.
18.
Blue Cross and Blue Shield Association. Contract holder acknowledges and agrees that:
(i) This Agreement is a contract solely between Contract holder and BCBSAZ, which is an
independent corporation operating under a license from the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans, (the
“Association”) permitting BCBSAZ to use the Blue Cross and Blue Shield Service Marks in
the State of Arizona; (ii) BCBSAZ is not contracting as the agent of the Association; (iii)
Contract holder has not entered into this Agreement based on any representations by the
Association, or any Blue Cross or Blue Shield plan other than BCBSAZ; and (iv) Contract
holder shall not seek to hold the Association or any other Blue Cross or Blue Shield plan
accountable or liable to Contract holder for any of BCBSAZ's obligations to the Contract
holder or Participants created under this Agreement. This Paragraph shall not create any
additional obligations whatsoever on the part of BCBSAZ other than those obligations
created under other provisions of this Agreement.
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19.
Survival. Any term that reasonably should survive termination of this Agreement is
deemed to survive termination of this Agreement.
Intending to be legally bound, the Parties have executed this Agreement as of its Effective Date.
BLUE CROSS AND BLUE SHIELD OF
ARIZONA, INC.
CITY OF CHANDLER
By: ____________________________________________
By: ____________________________________________
Print Name: ___________________________________ Print Name: __________________________________
Title: __________________________________________
Title: __________________________________________
Date: __________________________________________ Date: _________________________________________
APPROVED AS TO FORM:
By: ________________________________________
City Attorney
ATTEST:
By: ________________________________________
City Clerk
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10/15/2022
Vice President, Commercial Sales
Michael Groeger
Exhibit F
BCBSAZ Administrative Services Agreement
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APPROVED AS TO FORM:
By: ________________________________________
City Attorney
ATTEST:
By: ________________________________________
City Clerk
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Exhibit G
Supplemental Terms and Conditions to Administrative Services Agreement
Blue Cross and Blue Shield of Arizona, Inc., an Arizona non-profit corporation and an independent
licensee of the Blue Cross and Blue Shield Association (hereinafter referred to as "BCBSAZ"), and
City of Chandler (hereinafter referred to as the "Employer") entered into an Administrative
Services Agreement (“Agreement”) whereby BCBSAZ agreed to provide administrative services to
Employer’s health and welfare benefit plan (the “Plan”). Upon signature by both parties these
terms and conditions (“Terms and Conditions”) shall become part of the Agreement effective as of
the start of the initial term set forth in the Agreement.
ARTICLE 1. DEFINITIONS
For purposes of this Agreement, the following terms have the following meanings unless otherwise
expressly provided herein:
1.1
Allowed Amount means the amount payable by or through BCBSAZ for a Covered Service,
including any contracted discounts and amounts payable by a Participant under the terms
of the Plan and the Benefit Plan Booklet.
1.2
Application means the 100+ Employer Application.
1.3
Association means the Blue Cross and Blue Shield Association, an association of
independent Blue Cross and Blue Shield plans permitting BCBSAZ to use the Blue Cross
and Blue Shield service marks in the State of Arizona.
1.4
Covered Services means health care services and supplies rendered or delivered to a
Participant for which benefits are available under the Plan.
1.5
Eligible Dependent means a dependent eligible for benefits under the Plan as described in
the 100+ Employer Application and Benefit Plan Booklet.
1.6
Grandfathered Plan means coverage provided by a group health plan in which an
individual was enrolled on March 23, 2010 and which has not been modified or changed in
a manner which would cause it to lose its grandfathered status as provided by PPACA.
1.7
Network Provider means a hospital, health care facility, person or other provider of medical
services which has a written agreement with BCBSAZ, a vendor of BCBSAZ, or another Blue
Cross Blue Shield plan in accordance with Exhibit A.
1.8
Non-Grandfathered Plan means either coverage provided by a group health plan in
which an individual was not enrolled on March 23, 2010 or a group health plan which has
been modified or changed in a manner which caused it to lose its grandfathered status as
provided by PPACA.
1.9
Out-of-Network Services means Covered Services received by a Participant from any
Provider other than a Network Provider.
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1.10 Participant means any employee of Employer and any Eligible Dependent that is covered
by the Plan.
1.11 PPACA means the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) and
the Health Coverage and Education Reconciliation Act (Pub. L. No. 111-152), as amended,
and any regulations issued thereunder.
1.12 Provider means any hospital, health care facility, laboratory, person or entity duly
licensed to render Covered Services to a Participant or any other provider of medical
services, products, or supplies which are Covered Services subject to any definitions or
provisions of the Plan regarding providers or medical professionals whose services are
covered under the Plan.
1.13 Waiting Periods mean with respect to a group health plan and an individual who is a
potential participant or beneficiary in the group health plan, the period that must pass
before the individual is eligible to be covered for benefits under the terms of the Plan.
ARTICLE 2. DUTIES AND AUTHORITY OF BCBSAZ
2.1
BCBSAZ has agreed to provide the services specified in Attachment A to the Administrative
Services Agreement.
ARTICLE 3. EMPLOYER DUTIES AND ACKNOWLEDGEMENTS
3.1
Providers. Employer agrees that (i) BCBSAZ is not liable for any act or omission of any
Provider, nor is BCBSAZ responsible for a Provider's failure or refusal to render Covered
Services to a Participant, (ii) the use (or lack of use) of a descriptive term such as "Network"
or "non-Network" in describing any Provider is not a statement as to the professional ability
of the Provider, and (iii) the choice of Provider is exclusively that of the Participant. It is
understood and agreed that neither BCBSAZ nor the Plan is engaged in the practice of
medicine. Providers are solely responsible for all decisions regarding medical care and
treatment of Participants, and the traditional relationship between physician and patient
shall in no way be affected by or interfered with by any of the terms of the Plan of this
Agreement or any agreement between BCBSAZ and such Providers. Accordingly, the Plan
and this Agreement are in no way intended to affect the responsibility of Providers to
provide appropriate services to Participants.
3.2
Claims Determinations. Employer acknowledges and agrees that BCBSAZ is neither the
plan administrator nor a named fiduciary of the Plan. Employer acknowledges and agrees
that the fact that a Provider has prescribed, ordered, recommended, or approved a service
or supply does not make it a Covered Service or make the charge eligible for benefits under
the Plan and this Agreement, even though such service or supply is not specifically listed
as an exclusion under the Plan or this Agreement.
3.3
HDHP and HSA Option. For Employers offering Participants the option of enrolling in a
plan which may be paired with a health savings account (HSA), Employer will: (a) make the
establishment of HSAs completely voluntary; (b) not limit the ability of HSA eligible
individuals to move their funds to another HSA beyond restrictions imposed by the Internal
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Revenue Code; (c) not impose conditions on the utilization of HSA funds beyond those
permitted in the Internal Revenue Code; (d) not make or influence the investment
decisions with respect to funds contributed to HSAs; (e) not represent that the HSAs are a
welfare benefit plan established or maintained by the Employer; and (f) not receive
compensation in connection with an HSA. BCBSAZ is not responsible for any HSA which
may be established by a Participant or with determining whether a Participant is eligible to
establish an HSA.
3.4
HSA Integration Option. When a Participant wishes to have the high deductible plan
integrated with the HSA offered by BCBSAZ’s contracted HSA administrator, Employer shall
obtain from each such adult Participant an authorization pursuant to the HIPAA Privacy
Rule which authorizes BCBSAZ and its contracted vendors to provide to BCBSAZ’s
contracted HSA Administrator the Participant’s protected health information to facilitate
integration of the HSA and the HDHP. Employer agrees to retain the HIPAA authorizations
for the period of time required by HIPAA and provide copies to BCBSAZ upon request.
Employer will provide BCBSAZ with a list of all Enrollees who enroll in the HSA/HDHP that
clearly identifies which of these enrollees has provided the Employer with the HIPAA
authorization.
3.5
Mental Health Parity. If the Plan is not subject to ERISA and does not comply with the
Mental Health Parity and Addiction Equity Act of 2008, the Employer represents and
warrants that it has satisfied all the requirements to opt out from such Act including but
not limited to notifying all employees of the opt out prior to the beginning of the plan year
and is identified on the CMS website as having successfully opted out.
3.6
Qualified Medical Child Support Orders. Employer is responsible for determining whether
an order received by the Employer (or BCBSAZ) is a qualified medical child support order
under ERISA and/or Arizona law (and related regulations and amendments or successor
provisions) and whether the children named in such order are eligible for coverage under
the Plan and this Agreement. Employer shall not request that BCBSAZ terminate the
coverage of a minor child whose coverage is mandated by a court or administrative order
unless the Employer has written proof that the court or administrative order is no longer
in effect or that the child is enrolled in comparable health insurance coverage and that
coverage will take effect not later than the effective date of the termination of coverage as
required by A.R.S. Section 25-534. The Employer acknowledges and agrees that BCBSAZ
will assume that any request from the Employer to terminate the coverage of a minor child
whose coverage is mandated by a court or administrative order will mean that the
Employer has obtained such written proof.
3.7
Provider Agreements. Employer will comply with the participation agreements between
BCBSAZ and Providers. If the terms and conditions of such participation agreements
require the amendment or modification of this Agreement, BCBSAZ shall provide written
notice of such amendment or modification to the Employer. If the Plan conflicts with the
terms of the participation agreements between BCBSAZ and Providers, the terms and
conditions of the participation agreements shall control.
3.8
Participant Cost Sharing. Participants are responsible for payment of all applicable cost
sharing as well as expenses incurred for services that are not Covered Services, including
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services in excess of specified benefit maximums. Network Providers will seek payment
for these amounts directly from Participants.
3.9
Benefit Priority Designation. Employer acknowledges and agrees that all amounts owing
to BCBSAZ under this Agreement, as supplemented, including without limitation,
unreimbursed Covered Services, Administrative Fees, BlueCard Fees and Other Fees,
constitute contributions to an employee benefit plan for purposes of 11 U.S.C. § 507(a)(5).
ARTICLE 4. PLAN CHANGES BY EMPLOYER
4.1.
Plan Design. Employer is responsible for design of the Plan, including any modification or
termination of the Plan. From time to time during the term of this Agreement, Employer
may change the Plan’s details of operation, specific benefits, or other terms and conditions
provided that no such change shall be covered by this Agreement unless there is a prior
written acceptance by BCBSAZ. The Employer acknowledges that changes to a
Grandfathered Plan may result in the plan losing its grandfathered status.
4.2
Plan Changes. Employer agrees to provide BCBSAZ with a written description of changes
to the Plan at least thirty (30) days prior to the proposed effective date of the changes. Any
changes to BCBSAZ's processing system or payment policies and procedures required by
a change to the Plan and agreed to be BCBSAZ shall be made at an additional charge to the
Plan to be negotiated in good faith and mutually agreed upon by the Parties. In addition
to other available remedies, BCBSAZ may terminate this Agreement as a result of any
material modification of the Plan upon which BCBSAZ has not agreed, by providing 30 days’
prior written notice of termination.
ARTICLE 5. BLUECARD ADMINISTRATION
5.1
Out-of-Area Services. BCBSAZ has a variety of relationships with other Blue Cross and/or
Blue Shield Licensees referred to generally as "Inter-Plan Programs." Whenever
Participants access healthcare services outside the geographic area BCBSAZ serves, the
Claim(s) for those services may be processed through one of these Inter-Plan Programs
and presented to BCBSAZ for payment in accordance with the rules of the Inter-Plan
Programs policies then in effect. Typically, Participants, when accessing care outside the
geographic area BCBSAZ serves, obtain care from healthcare providers that have a
contractual agreement (i.e., are "participating providers") with the local Host Blue in that
other geographic area. In some instances, Participants may obtain care from non-
contracted healthcare providers (i.e., "non-participating providers"). BCBSAZ payment
practices in both instances are described in Exhibit A the Inter-Plan Programs available to
Participants under this Agreement are described generally in Exhibit A.
ARTICLE 6: PAYMENT DISCLOSURES
6.1
Preferred Drug List. With guidance from its Pharmacy and Therapeutics Committee,
BCBSAZ develops and adopts for its entire book of insured and administered business and
not on behalf of any specific individual or group benefit plan, a preferred drug list (PDL). A
copy of the current list is available on the BCBSAZ website. BCBSAZ may add and delete
drugs from the preferred drug list, or move drugs from one level on the list, to another, at
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any time. Employer hereby adopts the BCBSAZ preferred drug list, as it may be amended
from time to time, as the Employer’s Preferred Drug List and shall notify BCBSAZ if
Employer wishes to withdraw such approval. Employer acknowledges that withdrawal of
approval will affect Employer’s participation in the BCBSAZ pharmaceutical product rebate
program, and any administrative fee credit taken in lieu of rebates.
6.2
Recovery of Payment. If BCBSAZ pays a Provider, Participant, or ineligible person and such
payment is thirty-five ($35.00) dollars or more in excess of the amount actually owed,
BCBSAZ shall make a single written demand upon such person for the return of the
overpayment or improper payment. BCBSAZ shall have no further obligation with respect
to any such overpayment or improper payment to a Participant or payment to any
ineligible person, and in no event shall BCBSAZ be liable for such payments. Employer
agrees that BCBSAZ shall have no obligation to attempt to collect any overpayments of less
than thirty-five ($35.00) dollars. The above obligation does not apply to the extent the
erroneous payment was the result of incorrect eligibility information from Employer.
6.3
Payment for Inpatient Services. The BCBSAZ Allowed Amount for inpatient services is
referred to as the "Diagnosis Related Grouping" or "DRG." A DRG is a category of diagnoses
or procedures used to reimburse hospitals specific dollar amounts depending on the
category of reason for admission (diagnosis) or treatment (procedure). Some institutional
providers are paid on a per diem (per day) basis.
6.4
Pharmacy Rebate Contracts. The Plan Sponsor is responsible for design of the Plan,
including any modification or termination of the Plan, and retains sole and complete
control to select and change the formularies for its Plan.
BCBSAZ participates in contracts with pharmaceutical companies to receive rebate
payments (“rebate contracts”). Rebate payments may be based on factors such as
preferred drug list placement and the volume and/or market share of pharmaceutical
products used by Participants in this Plan, participants in other group plans, and BCBSAZ
subscribers. BCBSAZ participates in rebate contracts on its own behalf, for its entire book
of insured and administered business, and not on behalf of any specific individual or group
benefit plan. BCBSAZ reserves the right to negotiate, participate in and terminate existing
or future rebate contracts with pharmaceutical companies at any time, and in its sole and
absolute discretion. If BCBSAZ receives any rebates attributable to pharmaceutical
products covered under the terms and conditions of this Agreement, and used by
Participants of Employer’s Plan, BCBSAZ shall retain any such rebates and shall not remit
any rebate payments to Employer.
If applicable, at Employer’s request, the parties have agreed that BCBSAZ will provide
Employer with an administrative fee credit, in the amount specified on the rate sheet.
Employer acknowledges that it has negotiated this administrative fee credit as part of this
Agreement and that it and its group health plan have no right to, or legal interest in, any
rebates provided by pharmaceutical manufacturers to BCBSAZ. The Employer consents to
BCBSAZ’s retention of any and all such rebates.
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ARTICLE 7. LIMITATION OF LIABILITY AND INDEMNIFICATIONS
7.1
Scope of Responsibility. With respect to the Plan, the parties agree that BCBSAZ is not the
Plan administrator or a Plan fiduciary under ERISA (including PPACA) or COBRA (or
comparable provisions of other state or federal law). The Employer acknowledges and
agrees that it is the plan administrator and named fiduciary and is responsible for any
liability arising out of the requirements of COBRA, ERISA, the PHSA and the Internal
Revenue Code, including PPACA, (or comparable provisions of other state or federal law).
Both Parties acknowledge and agree that the Employer is responsible for compliance with
all applicable laws and regulations. BCBSAZ does not assume any responsibility for the
general policy direction of the Plan, the adequacy of its funding, or any act or omission or
any breach of duty by the Employer. BCBSAZ is not in any way to be deemed an insurer,
underwriter, or guarantor with respect to any benefits payable under the Plan, nor is
BCBSAZ a fiduciary under the Plan. BCBSAZ does not assume any risk, including but not
limited to, insurance and/or financial or credit risk, unless and only to the extent BCBSAZ
and the Employer have executed a Maximum Aggregate and Specific Liability Agreement.
7.2
Liability for Misrepresentation or Fraud. The Employer shall be liable for providing
misleading, false, or fraudulent statements and for failing to provide adequate, accurate
and timely information or notice to BCBSAZ under this Agreement. BCBSAZ reserves the
right to take whatever action it deems necessary and appropriate to return BCBSAZ to the
position it would have been in but for those misrepresentations, misstatements, or
omissions by Employer. Such actions shall include, but not be limited to, the right to
immediately terminate or rescind this Agreement.
7.3
Limitation of Liability. BCBSAZ shall not be liable for any loss or expense to the Employer
resulting from the performance of BCBSAZ under this Agreement, when BCBSAZ has
adhered to the framework of the policies, interpretations, rules, practices, and procedures
made or established by the Employer or has otherwise performed under this Agreement,
except for losses resulting directly from and to the extent of the gross negligence, fraud,
or willful misconduct of BCBSAZ, its directors, officers, employees, or agents.
7.6
Lawsuits by BCBSAZ. BCBSAZ may, on occasion, investigate opportunities to initiate or join
class action or other lawsuits premised on suspected conduct that results in higher payments by
third party payors, for example insurance companies, than otherwise would have been required.
BCBSAZ reviews these cases and makes a good faith decision based on the unique facts of each
case whether to file a lawsuit or participate in a pending matter. BCBSAZ may also bring lawsuits
against vendors or other entities to recover various economic damages. If BCBSAZ participates
as a plaintiff and recovers damages, those funds (unless determined to be plan assets under
ERISA) are retained by BCBSAZ to reduce overall administrative costs. The lawsuits are brought
on behalf of BCBSAZ and funds are not distributed to the Plan or Participants. This paragraph is
not intended to limit or waive any claims BCBSAZ may have against any person or entity.
ARTICLE 8. HIPAA BUSINESS ASSOCIATE PROVISIONS
8.1
Definitions. Any capitalized term used, but not defined, in this Article shall have the
meaning set forth in the HIPAA Rules. The HIPAA Rules include the Privacy, Security, Breach
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Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164. The “HIPAA Privacy
Rule” is at 45 CFR, part 160 and part 164, subparts A and E. The “HIPAA Security Rule” is at
45 C.F.R. Parts 160 and 164. The “HIPAA Breach Notification Rule” is at 45 CFR Part 164
Subpart D.
8.2
Certification. Employer certifies that the plan document of Plan has been amended to
comply with the requirements of 45 C.F.R. § 164.504(f)(2) and 45 C.F.R. §164.314(b),
including, but not limited to (a) prohibiting use or disclosure of Protected Health
Information for employment related actions, and (b) ensuring separation of records
between the Plan and Employer. The amendment provides the required satisfactory
assurance that Employer will appropriately safeguard and limit the use and disclosure of
the Plan Participants’ Protected Health Information that Employer may receive from Plan
or BCBSAZ to perform the Plan Administration Functions.
8.3
Privacy Of Protected Health Information.
a.
BCBSAZ will protect all Protected Health Information that BCBSAZ creates or
receives on Plan’s behalf or receives from Plan (or another Business Associate of
Plan) in the performance of its duties under the Agreement, as required by this
Agreement and applicable law. As a Business Associate, BCBSAZ recognizes and
agrees that it is obligated by law to meet the applicable provisions of the HIPAA
Rules.
b.
BCBSAZ is permitted to use or disclose Protected Health Information it creates or
receives for or from Plan, or a Business Associate of Plan, or to request Protected
Health Information on the Plan’s behalf as follows:
i.
BCBSAZ is permitted to request Protected Health Information on the Plan’s
behalf and to use and to disclose Protected Health Information it creates or
receives for or from the Plan, or a Business Associate of Plan, to perform its
obligations under this Agreement. Without limiting the foregoing, BCBSAZ is
permitted to disclose Protected Health Information to the Plan’s stop loss
carrier, the Plan’s designated utilization review agent, the Plan’s designated
broker and benefits consultant, the Plan’s auditor and any vendor the Plan
uses to perform enrollment, eligibility, COBRA Administration, HSA, HRA or
FSA administration or similar functions (collectively, “Plan Contractors”)
which such Plan Contractors request.
ii.
For any use, disclosure or request of Protected Health Information, BCBSAZ
shall utilize a Limited Data Set if practicable or, if not practicable, use,
disclose, and request of the Plan only the minimum amount of the Plan’s
Protected Health Information reasonably necessary to accomplish the
intended purpose of the use, disclosure or request. In addition, BCBSAZ
agrees to implement and follow appropriate minimum necessary policies in
the performance of its obligations under this Agreement.
iii.
BCBSAZ may use the Protected Health Information it creates or receives for
or from the Plan, or from another Business Associate of the Plan, for the
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administration of BCBSAZ’s wellness programs, to communicate with
Participants about value added products and services, for BCBSAZ’s
management and administration or to carry out BCBSAZ’s legal
responsibilities.
iv.
BCBSAZ may disclose Protected Health Information for the proper
management and administration of BCBSAZ or to carry out the legal
responsibilities of BCBSAZ, provided that disclosures are Required By Law,
or BCBSAZ obtains reasonable assurances from the person to whom the
information is disclosed that it will remain confidential and used or further
disclosed only as Required By Law or for the purpose for which it was
disclosed to the person, and the person notifies BCBSAZ of any instances of
which it is aware in which the confidentiality of the information has been
breached.
c.
BCBSAZ will neither use nor disclose Protected Health Information it creates or
receives for or from the Plan or from another Business Associate of the Plan, except
as permitted or required by this Agreement, as permitted or required by law, as
otherwise permitted in writing by the Plan, or as authorized by a particular
Participant with respect to their Protected Health Information.
d.
BCBSAZ may use and disclose PHI to provide Data Aggregation Services related to
the Plan’s Health Care Operations. BCBSAZ also may deidentify PHI it obtains or
creates in the course of providing services to Plan.
e.
BCBSAZ shall not directly or indirectly receive remuneration in exchange for PHI
except where consistent with applicable law.
f.
BCBSAZ shall not directly or indirectly receive payment for any use or disclosure of
PHI for marketing purposes except where consistent with applicable law or
pursuant to an individual authorization.
g.
BCBSAZ will use appropriate safeguards to prevent uses or disclosures of the
information other than as provided for or by this Agreement.
h.
BCBSAZ will require any of its subcontractors and agents, to which BCBSAZ is
permitted to disclose Protected Health Information, to provide reasonable
assurance, evidenced by written contract, that subcontractor or agent will comply
with the same privacy and security obligations as BCBSAZ with respect to such
Protected Health Information.
i.
Prior to requesting any Protected Health Information from BCBSAZ or directing
BCBSAZ to provide Protected Health Information to a Plan Contractor or other third-
party, the Employer and Plan shall ensure that they, and any of Plan’s Business
Associates, take any required actions and obtain any required authorizations which
may be necessary for such disclosure.
8.4
Safeguards for Securing Electronic Protected Health Information.
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a.
BCBSAZ will use appropriate administrative, technical, and physical safeguards that
reasonably and appropriately protect the integrity, confidentiality and availability of
Electronic Protected Health Information created or received for or from the Plan or
on the Plan’s behalf, consistent with the HIPAA Security Rule.
b.
BCBSAZ will require its agents and subcontractors, to whom it provides such
Electronic Protected Health Information, to implement reasonable and appropriate
safeguards to protect it, consistent with the HIPAA Security Rule.
8.5
Reporting.
a.
BCBSAZ will report to Plan, following discovery and without unreasonable delay, any
"Breach" of "Unsecured Protected Health Information" as these terms are defined
by the HIPAA Breach Notification Rule. BCBSAZ shall cooperate with Plan in
investigating the Breach and in meeting the Plan’s obligations under the Breach
Notification Rule and any other security breach notification laws. Any such report
shall include the identification (if known) of each individual whose Unsecured
Protected Health Information has been, or is reasonably believed by BCBSAZ to
have been, accessed, acquired, or disclosed during such Breach, along with any
other information required to be reported under the HIPAA Rules.
b.
BCBASAZ will report to the Plan any Security Incident, of which it becomes aware,
affecting Participant Electronic Protected Health Information and resulting in a
disclosure not permitted by this Agreement.
8.6
Access, Amendment And Disclosure Accounting.
a.
Upon receipt of the Plan’s written request, BCBSAZ will make available to the Plan
or, at the Plan’s direction, to the individual, Protected Health Information
maintained in a designated record set in accordance with 45 C.F.R. §164.524.
BCBSAZ shall make such information available in electronic format where directed
by Plan. If BCBSAZ receives such a request directly from a Participant, BCBSAZ will
provide such information directly to the Participant or person designated by the
Participant.
b.
Upon receipt of the written request of the Plan or a Participant, BCBSAZ will make
available Protected Health Information maintained in a designated record set for
amendment and will incorporate amendments to Protected Health Information
maintained in a designated record set in accordance with 45 C.F.R. §164.526.
c.
Upon receipt of the Plan’s written request in response to a request from a
Participant, BCBSAZ will make available to Plan or, at Plan’s direction, to the
Participant, information required to provide an accounting of disclosures in
accordance with 45 C.F.R. §164.528. If BCBSAZ receives a request for accounting
directly from a Participant, BCBSAZ will provide such accounting directly to the
Participant or person designated by the Participant.
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d.
BCBSAZ will make its internal practices, books, and records, relating to its use and
disclosure of the Protected Health Information it creates or receives for or from the
Plan, along with required documentation of security policies and procedures,
available to the U.S. Department of Health and Human Services for purposes of
determining compliance with HIPAA Administrative Simplification requirements.
8.7
Termination for Breach of Privacy or Security Obligations.
a.
Termination
Plan will have the right to terminate this Agreement if BCBSAZ has engaged in a
pattern of activity or practice that constitutes a material breach or violation of
BCBSAZ’s obligations regarding Plan’s Protected Health Information under this
Agreement and, on notice of such material breach or violation from Plan, fails to
take reasonable steps to cure the breach or end the violation. If BCBSAZ fails to
cure the material breach or end the violation within thirty (30) days after receipt of
Plan’s notice, Plan may terminate the Agreement by providing BCBSAZ written
notice of termination, stating the uncured material breach or violation that provides
the basis for the termination and specifying the effective date of the termination. If
for any reason Plan determines that BCBSAZ has breached the terms of this Article
9 and such breach has not been cured, but Plan determines that termination of the
Agreement is not feasible, Plan may report such breach to the U.S. Department of
Health and Human Services.
b.
Obligations upon Termination.
i.
Upon termination, cancellation, expiration or other conclusion of
Agreement, BCBSAZ will, if feasible, return to the Plan or destroy all
Protected Health Information that BCBSAZ created or received for or from
the Plan. If such information cannot feasibly be returned, BCBSAZ will limit
its further use or disclosure of that Protected Health Information to those
purposes that make return or destruction of that Protected Health
Information infeasible.
ii.
BCBSAZ’s obligation to protect the privacy of the Protected Health
Information it created or received for or from the Plan will be continuous
and survive termination, cancellation, expiration or other conclusion of
Agreement.
ARTICLE 9. GENERAL PROVISIONS
9.1
Amendment. The Agreement may be modified only through a written Amendment
executed by authorized persons for both parties, however, BCBSAZ may alter, amend, or
modify this Agreement, the Benefit Plan Booklet(s), and its performance under this
Agreement as BCBSAZ in its sole discretion determines may be necessitated by applicable
state or federal law or by the terms and conditions of various participation agreements
between BCBSAZ and Providers. Changes to the Agreement, including the addition of work
or materials, the revision of payment terms, or the substitution of work or materials,
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directed by a person who is not specifically authorized by the City in writing or made
unilaterally by BCBSAZ are violations of the Agreement. Except as stated in this Section,
any such changes, including unauthorized written Amendments shall be void and without
effect, and BCBSAZ shall not be entitled to any claim under this Agreement based on such
changes.
9.2
Attorneys’ Fees. In any action to enforce the terms of this Agreement, the successful party,
defined as the net winner considering all claims and counterclaims actually adjudicated,
shall be entitled to an award of its reasonable attorneys’ fees and costs as provided by
A.R.S. section 12-341.01.
9.3
Relationship to the Association. The Plan, on behalf of itself and its participants, hereby
expressly acknowledges its understanding this Agreement constitutes a contract solely
between the Plan and BCBSAZ, which is an independent corporation operating under a
license from the Blue Cross and Blue Shield Association, an association of independent
Blue Cross and Blue Shield Plans, (the “Association”) permitting BCBSAZ to use the Blue
Cross and Blue Shield Service Mark[s] in Arizona, and that BCBSAZ is not contracting as the
agent of the Association. The Plan, on behalf of itself and its participants, further
acknowledges and agrees that it has not entered into this Agreement based upon
representations by any person other than BCBSAZ and that no person, entity, or
organization other than BCBSAZ shall be held accountable or liable to the Plan for any of
BCBSAZ’s obligations to the Plan created under this Agreement. This paragraph shall not
create any additional obligations whatsoever on the part of BCBSAZ other than those
obligations created under other provisions of this agreement.
9.4
Independent Contractors. BCBSAZ is an independent contractor with respect to the
services being performed under this Agreement and shall not for any purpose be deemed
an employee of the Plan or Employer, nor shall BCBSAZ and the Plan or Employer be
deemed partners, joint venturers, or governed by any legal relationship other than that of
independent contractor.
9.5
Non-Assignability of Right of Payment. Payment for Covered Services shall be made
directly to the Provider of such Covered Services if that Provider has a participation
agreement with BCBSAZ or direct payment to that Provider is required under agreements
between BCBSAZ and the Association and/or other independent licensees of the
Association. If a Provider is not in either of these categories, the payment of Covered
Services shall be made directly to the Participant, except as may otherwise be required by
applicable state or federal law. Rights to payment available under this Agreement are not
assignable.
9.6
Non-Disclosure of Proprietary Information. Employer and Plan acknowledge that each has
received, or is likely to receive, information which is proprietary or confidential to BCBSAZ
as well as confidential information belonging to another Blue Cross and Blue Shield plan
(“Blue Plan”) or the Blue Cross Blue Shield Association (the “Association”) (collectively,
“Proprietary Information”). The term Proprietary Information shall mean: (a) any
information provided by BCBSAZ to Employer or Plan which a reasonable person would
regard as confidential including, without limitation, information of BCBSAZ, a Blue Plan or
the Association pertaining to providers, rates, pricing, proposed products, strategies,
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members, trade secrets, policies, procedures, data, processes and financial information;
(b) information acquired by BCBSAZ under terms limiting or protecting the disclosure
thereof; and (c) any information marked confidential. Employer and Plan acknowledge
that the Proprietary Information is confidential and proprietary to BCBSAZ, the applicable
Blue Plan or the Association and each agrees that it shall not: (1) resell Proprietary
Information; (2) de- aggregate any Proprietary Information to identify BCBSAZ, another
Blue Plan, or any other employer or participants of another employer; (3) comingle
Proprietary Information unless approved by BCBSAZ; or (4) disclose the Proprietary
Information to any third party without the prior written consent of BCBSAZ. Employer and
Plan shall not utilize the Proprietary Information for any purpose not specifically permitted
in this Agreement or otherwise permitted by BCBSAZ in advance and in writing.
Additionally, Employer and Plan agree to destroy any Proprietary Information upon
conclusion of the purpose for which it was requested or, where destruction is not feasible
for legal or licensure reasons, continue to maintain the confidentiality of the Proprietary
Information as set forth in this Agreement. BCBSAZ may audit Employer and Plan to
confirm compliance with the terms of this provision.
9.7
Parties to the Agreement. This Agreement is between BCBSAZ and the Plan and does not
create any rights or legal relationships between BCBSAZ and any Participants. Employer
represents and warrants all entities covered under this Agreement qualify as a single
employer under 26 U.S.C. §414 (b), (c), (m) or (o).
9.8
Severability. If any provision of this Agreement is held to be illegal, invalid, or
unenforceable under current or future laws or regulations effective during the term of this
Agreement, (a) the illegal, invalid, or unenforceable provision shall be severed from this
Agreement, (b) this Agreement shall be construed and enforced as if such illegal, invalid, or
unenforceable provision had never comprised a part of this Agreement, and (c) the
remaining provisions shall remain in full force and effect and shall not be affected by such
illegal, invalid or unenforceable provision or by its severance.
9.9
Successors and Assigns. The provisions of this Agreement shall be binding upon and inure
to the benefit of the Parties, their permissible successors, and their permissible assigns.
9.10 Use of Trade Name. The Employer agrees not to use the corporate name or any trade
name, trademark, or service mark of BCBSAZ, or of any pharmaceutical manufacturers or
vendor firms contracted with BCBSAZ, in any advertising, publications, press releases,
brochures, or other public communications without the prior written consent of BCBSAZ,
the pharmaceutical manufacturer, or vendor, as applicable.
9.11 Massachusetts. Employer acknowledges and agrees that: (a) Employer is aware
Massachusetts enacted health reform legislation which requires, among other things,
Massachusetts residents to have health insurance that qualifies as "creditable coverage"
under Massachusetts law and which imposes significant penalties on Massachusetts
residents and their employers who fail to comply with Massachusetts creditable coverage
related laws and regulations; (b) BCBSAZ does not perform any of the duties required of
employers with Massachusetts resident employees, including but not limited to: (i) making
electronic filing(s) with Massachusetts regulators; (ii) sending the Massachusetts Form
1099 HC to Massachusetts residents; (iii) assessing whether BCBSAZ plans satisfy, in whole
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or in part, Massachusetts credible coverage requirements; (iv) making any representation
that any BCBSAZ coverage qualifies as "creditable coverage" under Massachusetts law.
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Exhibit G 1
BlueCard HMO
Out-of-Area Services
Overview
BCBSAZ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred
to generally as “Inter-Plan Arrangements.” These Inter-Plan Arrangements operate under rules
and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever
Participants access healthcare services outside the geographic area BCBSAZ serves, the claim for
those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan
Arrangements are described generally below.
Typically, when accessing care outside the geographic area BCBSAZ serves, Participants obtain
care from healthcare providers that have a contractual agreement (“participating providers”) with
the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In
some instances, Participants may obtain care from healthcare providers in the Host Blue
geographic area that do not have a contractual agreement (“nonparticipating providers”) with the
Host Blue. BCBSAZ remain responsible for fulfilling its contractual obligations to Employer.
BCBSAZ payment practices in both instances are described below.
•
BCBSAZ Narrow Network Benefit Plan - BCBSAZ covers only limited healthcare services
received outside of BCBSAZ’s service area (“Out-of-Area Covered Healthcare Services”). Emergency
services and EGID and Medical Foods formulas are covered when provided by providers
contracted with a Host Blue and when provided by non-contracted providers. All other covered
services must be obtained from providers contracted with a Host Blue.
•
BCBSAZ Statewide Benefit Plan - BCBSAZ covers healthcare services received outside of
our service area (“Out-of-Area Covered Healthcare Services”). Emergency services and EGID and
Medical Foods formulas are covered when provided by providers contracted with a Host Blue and
when provided by non-contracted providers. All other covered services must be obtained from
providers contracted with a Host Blue.
Inter-Plan Arrangements Eligibility – Claim Types
All claim types are eligible to be processed through Inter-Plan Arrangements, as described above,
except for all dental care benefits (except when paid as medical claims/benefits), and those
prescription drug benefits or vision care benefits that may be administered by a third party
contracted by BCBSAZ to provide the specific service or services.
A.
BlueCard® Program
The BlueCard® Program is an Inter-Plan Arrangement. Under this Arrangement, when
Participants access Out-of-Area Covered Services within the geographic area served by a
Host Blue the Host Blue will be responsible for contracting and handling all interactions
with its participating healthcare providers. The financial terms of the BlueCard Program
are described generally below.
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Liability Calculation Method Per Claim
1.
Participant Liability Calculation
Unless subject to a fixed-dollar copayment, the calculation of Participant liability on
claims for Out-of-Area Covered Services processed through the BlueCard Program
will be based on the lower of the participating provider's billed charges for Out-of-
Area Covered Services or the negotiated price made available to BCBSAZ by the Host
Blue.
2.
Employer Liability Calculation
The calculation of Employer liability on claims for Covered Services processed
through the BlueCard Program will be based on the negotiated price made available
to BCBSAZ by the Host Blue. Sometimes, this negotiated price may be greater for a
given service or services than the billed charge in accordance with how the Host
Blue has negotiated with its participating provider(s) for specific healthcare services.
In cases where the negotiated price exceeds the billed charge, Employer may be
liable for the excess amount even when the Participant’s deductible has not been
satisfied. This excess amount reflects an amount that is necessary to secure (a)
the provider’s participation in the network, and (b) the overall discount negotiated
by the Host Blue. The entire contracted price is paid to the provider even when
the contracted price is greater than the billed charge.
Claims Pricing
Host Blues determine a negotiated price, which is reflected in the terms of each Host Blue’s
provider contracts. The negotiated price made available to BCBSAZ by the Host Blue may
be represented by one of the following:
(i)
An actual price. An actual price is a negotiated rate of payment in effect at the time
a claim is processed without any other increases or decreases; or
(ii)
An estimated price. An estimated price is a negotiated rate of payment in effect at
the time a claim is processed, reduced or increased by a percentage to take into
account certain payments negotiated with the provider and other claim- and non-
claim-related transactions. Such transactions may include, but are not limited to,
anti-fraud and abuse recoveries, provider refunds not applied on a claim-specific
basis, retrospective settlements and performance-related bonuses or incentives; or
(iii)
An average price. An average price is a percentage of billed charges for Out-of-Area
Covered Healthcare Services in effect at the time a claim is processed representing
the aggregate payments negotiated by the Host Blue with all of its providers or a
similar classification of its providers and other claim- and non-claim-related
transactions. Such transactions may include the same ones as noted above for an
estimated price.
The Host Blue determines whether or not it will use an actual price, an estimated price or
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an average price. The use of estimated or average pricing may result in a difference
(positive or negative) between the price the Employer pays on a specific claim and the
actual amount the Host Blue pays to the provider.
However, the BlueCard Program requires that the amount paid by the Participant and
Employer is a final price; no future price adjustment will result in increases or decreases to
the pricing of past claims. Any positive or negative differences in estimated or average
pricing are accounted for through variance accounts maintained by the Host Blue and are
incorporated into future claim prices. As a result, the amounts charged to Employer will
be adjusted in a following year, as necessary, to account for over- or underestimation of
past years’ prices. The Host Blue will not receive compensation from how the estimated
price or average price methods, described above, are calculated.
Because all amounts paid are final, neither positive variance account amounts (funds
available to be paid in the following year), nor negative variance amounts (the funds
needed to be received in the following year), are due to or from Employer. If Employer
terminates, Employer will not receive a refund or charge from the variance account.
Variance account balances are small amounts relative to the overall paid claims amounts
and will be drawn down over time. The timeframe for their liquidation depends on
variables, including, but not limited to, overall volume/number of claims processed and
variance account balance. Variance account balances may earn interest at the federal
funds or similar rate. Host Blues may retain interest earned on funds held in variance
accounts.
Federal/State Taxes/Surcharges/Fees
In some instances, federal or state laws or regulations may impose a surcharge, tax, or
other fee that applies to self-funded accounts. If applicable, BCBSAZ will disclose any such
surcharge, tax or other fee to Employer, which will be Employer liability.
Return of Overpayments
Recoveries of overpayments from a Host Blue or its participating and nonparticipating
providers can arise in several ways, including, but not limited to, anti-fraud and abuse
recoveries, provider/hospital bill audits, credit balance audits, utilization review refunds
and unsolicited refunds. Recovery amounts determined in the ways noted above will be
applied so that corrections will be made, in general, on a claim-by-claim or prospective
basis. If recovery amounts are passed on a claim-by-claim basis from a Host Blue to
BCBSAZ, they will be credited to Employer’s account. In some cases, the Host Blue will
engage a third party to assist in identification or collection of overpayments. The fees of
such a third party may be charged to Employer as a percentage of the recovery.
Unless otherwise agreed to by the Host Blue, BCBSAZ will request adjustments from the
Host Blue for full refunds from providers due to the retroactive cancellation of membership
but only for one year after the date of the Inter-Plan financial settlement process for the
original claim. In some cases, recovery of claim payments associated with a retroactive
cancellation may not be possible if, as an example, the recovery conflicts with the Host
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Blue’s state law or provider contracts or would jeopardize the Host Blue’s relationship with
its providers.
BlueCard Fees and Compensation
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under the BlueCard Program to pay to the Host
Blues, to the Association and/or to vendors of BlueCard Program-related services, as
described below. BlueCard Program Fees and compensation may be revised from time to
time as described in section I.D below. BCBSAZ will charge these fees as follows:
Only the BlueCard Program Access Fee and the BlueCard Program Administrative Expense
Allowance (AEA) fee may be charged separately each time a claim is processed through the
BlueCard Program. All other BlueCard Program-related fees are included in the
Administrative Charges.
The Access Fee is charged by the Host Blue to BCBSAZ for making the applicable Host Blue’s
provider network available to Employer’s Participants. The Access Fee will not apply if the
provider does not participate in the applicable Host Blue’s network. The Access Fee is
charged on a per- claim basis and is charged as a percentage of the discount/differential
BCBSAZ receives from the applicable Host Blue subject to a maximum of $2,000 per claim.
When charged, BCBSAZ passes the Access Fee directly on to Employer.
The AEA Fee is a fixed per-claim dollar amount charged by the Host Blue to BCBSAZ for
administrative services that the Host Blue provides in processing claims for Employer’s
Participants. The dollar amount is normally based on the type of claim (e.g. institutional,
professional, international, etc.) and can also be based on the size of your group
enrollment. When charged, BCBSAZ passes the AEA Fee directly on to Employer.
See Administrative Service Agreement, Caveats for the BlueCard Program Access Fee and
AEA Fee and for Employer’s general administrative fee.
BlueCard Program Access Fees
A BlueCard Program Access Fee may be charged only if the Host Blue’s arrangement with
its provider prohibits billing Participants for amounts in excess of the negotiated payment.
However, a provider may bill Participants for non-covered healthcare services and for cost
sharing (for example, deductibles, copayments and/or coinsurance) related to a particular
claim.
How the BlueCard Program Access Fee Affects Employer
Sometimes the Access Fee is a negative amount, which is known as an Access Fee Credit.
Any Access Fee Credits will be credited to BCBSAZ, and BCBSAZ will pass the entire Access
Fee Credit on to Employer.
Instances may occur in which the claim payment is zero or BCBSAZ pays only a small
amount because the amounts eligible for payment were applied to patient cost sharing
(such as a deductible or coinsurance). In these instances, BCBSAZ will pay the Host Blue’s
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Access Fee and pass it along to BCBSAZ as stated above even though Employer paid little
or had no claim liability.
B.
Nonparticipating Providers Outside BCBSAZ Service Area
Participant Liability Calculation
In General
When Out-of-Area Covered Healthcare Services are provided outside of BCBSAZ service
area by nonparticipating providers, the amount(s) a Participant pays for such services will
generally be based on either the Host Blue’s nonparticipating provider local payment or
the pricing arrangements required by applicable state law. Payments for out-of-network
emergency services will be governed by applicable federal and state law.
Exceptions
In some exception cases, BCBSAZ may pay claims from nonparticipating providers for Out-
of-Area Covered Healthcare Services based on the provider’s billed charge. This may occur
in situations where a Participant did not have reasonable access to a participating provider,
as determined by BCBSAZ in BCBSAZ’s sole and absolute discretion or by applicable state
law. In other exception cases, BCBSAZ may pay such claims based on the payment
BCBSAZ would make if BCBSAZ were paying a nonparticipating provider for the same
covered healthcare services inside BCBSAZ‘s service area, as described elsewhere in this
Agreement. This may occur where the Host Blue’s corresponding payment would be more
than BCBSAZ in-service area nonparticipating provider payment. BCBSAZ may choose to
negotiate a payment with such a provider on an exception basis.
Fees and Compensation
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under applicable Inter-Plan Arrangement
requirements to pay to the Host Blues, to the Blue Cross Blue Shield Association and/or to
vendors of Inter-Plan Arrangement- related services. Fees and compensation under
applicable Inter-Plan Arrangements may be revised from time to time as provided for in
section I.D below
Specifically, BCBSAZ must pay an administrative fee to the Host Blue, and Employer further
agrees to reimburse BCBSAZ for any such administrative fee as set forth herein.
C.
Blue Cross Blue Shield Global Core
General Information
If Participants are outside the United States (hereinafter: “BlueCard service area”), they may
be able to take advantage of BCBS Global Core when accessing Covered Services. BCBS
Global Core is unlike the BlueCard Program available in the BlueCard service area in certain
ways. For instance, although BCBS Global Core assists Participants with accessing a
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network of inpatient, outpatient and professional providers, the network is not served by
a Host Blue. As such, when Participants receive care from providers outside the BlueCard
service area, the Participants will typically have to pay the providers and submit the claims
themselves to obtain reimbursement for these services.
□
Inpatient Services
In most cases, if Participants contact the BlueCard Worldwide Service Center for
assistance, hospitals will not require Participants to pay for covered inpatient
services, except for their cost-share amounts. In such cases, the hospital will
submit Participant claims to the BCBS Global Core Service Center to initiate claims
processing. However, if the Participant paid in full at the time of service, the
Participant must submit a claim to obtain reimbursement for Covered Services.
Participants must contact BCBSAZ to obtain precertification for non-emergency
inpatient services.
□
Outpatient Services
Physicians, urgent care centers and other outpatient providers located outside the
BlueCard service area will typically require Participants to pay in full at the time of
service. Participants must submit a claim to obtain reimbursement for Covered
Services.
□
Submitting a BCBS Global Core Claim
When Participants pay for Covered Services outside the BlueCard service area, they
must submit a claim to obtain reimbursement. For institutional and professional
claims, Participants should complete a BCBS Global Core claim form and send the
claim form with the provider’s itemized bill(s) to the service center (the address is
on the form) to initiate claims processing. The claim form is available from BCBSAZ,
the service center or online at www.bcbsglobalcore.com. If Participants need
assistance with their claim submissions, they should call the service center at
1.800.810.BLUE (2583) or call collect at 1.804.673.1177, 24 hours a day, seven days
a week.
D.
Modifications or Changes to Inter-Plan Arrangement Fees or Compensation
Modifications or changes to Inter-Plan Arrangement fees are generally made effective Jan.
1 of the calendar year, but they may occur at any time during the year. In the case of any
such modifications or changes, BCBSAZ shall provide Employer with at least thirty (30) days’
advance written notice of any modification or change to such Inter-Plan Arrangement fees
or compensation describing the change and the effective date thereof and Employer’s right
to terminate this Agreement without penalty by giving written notice of termination before
the effective date of the change. If Employer fails to respond to the notice and does not
terminate this Agreement during the notice period, Employer will be deemed to have
approved the proposed changes, and BCBSAZ will then allow such modifications to become
part of this Agreement.
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Exhibit G 1 (Continued)
BlueCard PPO
Out-of-Area Services
Overview
BCBSAZ has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred
to generally as “Inter-Plan Arrangements.” These Inter-Plan Arrangements operate under rules
and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever
Participants access healthcare services outside the geographic area BCBSAZ serves, the claim for
those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan
Arrangements are described generally below.
Typically, when accessing care outside the geographic area BCBSAZ serves, Participants obtain
care from healthcare providers that have a contractual agreement (“participating providers”) with
the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In
some instances, Participants may obtain care from healthcare providers in the Host Blue
geographic area that do not have a contractual agreement (“nonparticipating providers”) with the
Host Blue. B C B S A Z remains responsible for fulfilling its contractual obligations to Employer.
BCBSAZ payment practices in both instances are described below.
This disclosure describes how claims are administered for Inter-Plan Arrangements and the fees
that are charged in connection with Inter-Plan Arrangements. Note that dental care benefits
(except when not paid as medical claims/benefits), and those prescription drug benefits or vision
care benefits that may be administered by a third party contracted by BCBSAZ to provide the
specific service or services are not processed through Inter-Plan Arrangements.
A.
BlueCard® Program
The BlueCard® Program is an Inter-Plan Arrangement. Under this Arrangement, when
Participants access Covered Services within the geographic area served by a Host Blue, the
Host Blue will be responsible for contracting and handling all interactions with its
participating healthcare providers. The financial terms of the BlueCard Program are
described generally below.
1.
Liability Calculation Method Per Claim – In General
a.
Participant Liability Calculation
Unless subject to a fixed dollar copayment, the calculation of the Participant
liability on claims for Covered Services will be based on the lower of the
participating provider's billed charges for Covered Services or the negotiated
price made available to BCBSAZ by the Host Blue.
b.
Employer Liability Calculation
The calculation of Employer liability on claims for Covered Services
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processed through the BlueCard Program will be based on the negotiated
price made available to BCBSAZ by the Host Blue. Sometimes, this
negotiated price may be greater for a given service or services than the billed
charge in accordance with how the Host Blue has negotiated with its
participating healthcare provider(s) for specific healthcare services. In cases
where the negotiated price exceeds the billed charge, Employer may be
liable for the excess amount even when the Participant’s deductible has not
been satisfied. This excess amount reflects an amount that may be
necessary to secure (a) the provider’s participation in the network and/or (b)
the overall discount negotiated by the Host Blue. In such a case, the entire
contracted price is paid to the provider, even when the contracted price is
greater than the billed charge.
2.
Claims Pricing
Host Blues determine a negotiated price, which is reflected in the terms of each
Host Blue’s provider contracts. The negotiated price made available to BCBSAZ by
the Host Blue may be represented by one of the following:
(i)
An actual price. An actual price is a negotiated rate of payment in effect at
the time a claim is processed without any other increases or decreases; or
(ii)
An estimated price. An estimated price is a negotiated rate of payment in
effect at the time a claim is processed, reduced or increased by a percentage
to take into account certain payments negotiated with the provider and
other claim- and non- claim-related transactions. Such transactions may
include, but are not limited to, anti-fraud and abuse recoveries, provider
refunds not applied on a claim-specific basis, retrospective settlements and
performance-related bonuses or incentives; or
(iii)
An average price. An average price is a percentage of billed charges for
Covered Services in effect at the time a claim is processed representing the
aggregate payments negotiated by the Host Blue with all of its healthcare
providers or a similar classification of its providers and other claim- and non-
claim-related transactions. Such transactions may include the same ones as
noted above for an estimated price.
The Host Blue determines whether it will use an actual, estimated or average price.
The use of estimated or average pricing may result in a difference (positive or
negative) between the price Employer pays on a specific claim and the actual
amount the Host Blue pays to the provider. However, the BlueCard Program
requires that the amount paid by the Participant and Employer is a final price; no
future price adjustment will result in increases or decreases to the pricing of past
claims.
Any positive or negative differences in estimated or average pricing are accounted
for through variance accounts maintained by the Host Blue and are incorporated
into future claim prices. As a result, the amounts charged to Employer will be
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adjusted in a following year, as necessary, to account for over- or underestimation
of the past years’ prices. The Host Blue will not receive compensation from how
the estimated price or average price methods, described above, are calculated.
Because all amounts paid are final, neither positive variance account amounts
(funds available to be paid in the following year), nor negative variance amounts
(the funds needed to be received in the following year), are due to or from
Employer. If Employer terminates, Employer will not receive a refund or charge from
the variance account.
Variance account balances are small amounts relative to the overall paid claims
amounts and will be drawn down over time.
The
timeframe
for
their
liquidation depends on variables, including, but not limited to, overall
volume/number of claims processed and variance account balance. Variance
account balances may earn interest at the federal funds rate or similar rate. Host
Blues may retain interest earned on funds held in variance accounts.
3.
BlueCard Program Fees and Compensation
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under the BlueCard Program to pay to the
Host Blues, to the Association and/or to vendors of BlueCard Program-related
services. The specific BlueCard Program fees and compensation that are charged
to Employer are set forth in Administrative Service Agreement, Caveat. BlueCard
Program Fees and compensation may be revised from time to time as described in
section I.H below.
B.
Negotiated Arrangements
With respect to one or more Host Plans, instead of using the BlueCard Program, BCBSAZ
may process your Participant claims for Covered Services through Negotiated
Arrangements.
In addition, if BCBSAZ and Employer have agreed that (a) Host Blue(s) shall make available
(a) custom healthcare provider network(s) in connection with this Agreement, then the
terms and conditions set forth in BCBSAZ’s Negotiated Arrangement(s) for National
Accounts with such Host Blue(s) shall apply. These include the provisions governing the
processing and payment of claims when Participants access such network(s). In negotiating
such arrangement(s), BCBSAZ is not acting on behalf of or as an agent for Employer,
Employer’s group health plan or Employer Participants.
Participant Liability Calculation
Participant liability calculation will be based on the lower of either billed charges for
Covered Services or negotiated price (refer to the description of negotiated price under
Section A., BlueCard Program, as stated above) that the Host Blue makes available to
BCBSAZ and that allows Employer’s Participants access to negotiated participation
agreement networks of specified participating providers outside of the BCBSAZ service
area.
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Under certain circumstances, if BCBSAZ pays the Healthcare Provider amounts that are the
responsibility of the Participant, BCBSAZ may collect such amounts from the Participant.
In situations where participating agreements allow for bulk settlement reconciliations for
Episode- Based Payment/Bundled Payments, BCBSAZ may include a factor for such
settlement reconciliations as part of the fees BCBSAZ charges to Employer.
Where Employer agrees to use reference-based benefits, if offered, which are service-
specific benefit dollar limits for specific procedures, based on a Host Blue’s local market
rates, Participants will be responsible for the amount that the healthcare provider bills for
a specified procedure above the reference benefit limit for that procedure. For a
participating provider, that amount will be the difference between the negotiated price and
the reference benefit limit. For a nonparticipating provider, that amount will be the
difference between the provider’s billed charge and the reference benefit limit. Where a
reference benefit limit exceeds either a negotiated price or a provider’s billed charge, the
Participant will incur no liability, other than any applicable Participant cost sharing under
this Agreement.
Fees and Compensation
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under applicable Inter-Plan Arrangement
requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-Plan
Arrangement-related services. Fees and compensation under applicable Inter-Plan
Arrangements may be revised from time to time as described in Section I.H below. In
addition, the participation agreement with the Host Blue may provide that BCBSAZ must
pay an administrative and/or a network access fee to the Host Blue, and Employer further
agrees to reimburse BCBSAZ for any such applicable administrative and/or network access
fees. The specific fees and compensation that are charged to Employer under Negotiated
Arrangements are set forth in Administrative Service Agreement, Caveat.
C.
Special Cases: Value-Based Programs
Value-Based Programs Overview
Employer’s Participants may access Covered Services from providers that participate in a
Host Blue’s Value-Based Program. Value-Based Programs may be delivered either through
the BlueCard Program or a Negotiated Arrangement. These Value-Based Programs may
include, but are not limited to, Accountable Care Organizations, Global Payment/Total Cost
of Care arrangements, Patient Centered Medical Homes and Shared Savings
arrangements.
Value-Based Programs Definitions
Accountable Care Organization (ACO): A group of healthcare providers who agree to
deliver coordinated care and meet performance benchmark for quality and affordability in
order to manage the total cost of care for their member populations.
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Care Coordination: Organized, information-driven patient care activities intended to
facilitate the appropriate responses to a Participant’s healthcare needs across the
continuum of care.
Care Coordinator: An individual within a provider organization who facilitates Care
Coordination for patients.
Care Coordinator Fee: A fixed amount paid by a Blue Cross and/or Blue Shield Licensee to
providers periodically for Care Coordination under a Value-Based Program.
Global Payment/Total Cost of Care: A payment methodology that is defined at the patient
level and accounts for either all patient care or for a specific group of services delivered to
the patient such as outpatient, physician, ancillary, hospital services and prescription
drugs.
Negotiated Arrangement (a.k.a., Negotiated National Account Arrangement): An
agreement negotiated between a Control/Home Licensee and one or more Par/Host
Licensees for any National Account that is not delivered through the BlueCard Program.
Patient-Centered Medical Home (PCMH): A model of care in which each patient has an
ongoing relationship with a primary care physician who coordinates a team to take
collective responsibility for patient care and, when appropriate, arranges for care with
other qualified physicians.
Provider Incentive: An additional amount of compensation paid to a healthcare provider
by a Blue Cross and/or Blue Shield Plan, based on the provider's compliance with agreed-
upon procedural and/or outcome measures for a particular [group/population] of covered
persons.
Shared Savings: A payment mechanism in which the provider and payer share cost savings
achieved against a target cost budget based upon agreed upon terms and may include
downside risk.
Value-Based Program (VBP): An outcomes-based payment arrangement and/or a
coordinated care model facilitated with one or more local providers that is evaluated
against cost and quality metrics/factors and is reflected in provider payment.
Value-Based Programs under the BlueCard Program
Value-Based Programs Administration
Under Value-Based Programs, a Host Blue may pay providers for reaching agreed-upon
cost/quality goals in the following ways: retrospective settlements, Provider Incentives,
share of target savings, Care Coordinator Fees and/or other allowed amounts.
The Host Blue may pass these provider payments to BCBSAZ, which BCBSAZ will pass
directly on to Employer as either an amount included in the price of the claim or an amount
charged separately in addition to the claim.
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When such amounts are included in the price of the claim, the claim may be billed using
one of the following pricing methods, as determined by the Host Blue:
(i)
Actual Pricing: The charge to accounts for Value-Based Programs incentives/Shared
Savings settlements is part of the claim. These charges are passed to Employer via
an enhanced provider fee schedule.
(ii)
Supplemental Factor: The charge to accounts for Value-Based Programs
incentives/Shared Savings settlements is a supplemental amount that is included in
the claim as an amount based on a specified supplemental factor (e.g., a small
percentage increase in the claim amount). The supplemental factor may be
adjusted from time to time.
When such amounts are billed separately from the price of the claim, they may be
billed as follows:
□
Per Member Per Month (PMPM) Billings: Per Member Per Month billings for
Value- Based Programs incentives/Shared Savings settlements to accounts
are outside of the claim system. BCBSAZ will pass these Host Blue charges
directly through to Employer as a separately identified amount on the group
billings.
The amounts used to calculate either the supplemental factors for estimated
pricing or PMPM billings are fixed amounts that are estimated to be
necessary to finance the cost of a particular Value-Based Program. Because
amounts are estimates, there may be positive or negative differences based
on actual experience, and such differences will be accounted for in a
variance account maintained by the Host Blue (in the same manner as
described in the BlueCard claim pricing section above) until the end of the
applicable
Value-Based
Program
payment
and/or
reconciliation
measurement period. The amounts needed to fund a Value-Based Program
may be changed before the end of the measurement period if it is
determined that amounts being collected are projected to exceed the
amount necessary to fund the program or if they are projected to be
insufficient to fund the program.
At the end of the Value-Based Program payment and/or reconciliation
measurement period for these arrangements, Host Blues will do one of the
following:
□
Use any surplus in funds in the variance account to fund Value-Based
Program payments or reconciliation amounts in the next measurement
period.
□
Address any deficit in funds in the variance account through an adjustment
to the PMPM billing amount or the reconciliation billing amount for the next
measurement period.
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The Host Blue will not receive compensation resulting from how estimated,
average or PMPM price methods, described above, are calculated. If
Employer terminates, Employer will not receive a refund or charge from the
variance account. This is because any resulting surpluses or deficits would
be eventually exhausted through prospective adjustment to the settlement
billings in the case of Value-Based Programs. The measurement period for
determining these surpluses or deficits may differ from the term of this
Agreement.
Variance account balances are small amounts relative to the overall paid
claims amounts and will be drawn down over time. The timeframe for their
liquidation depends on variables, including, but not limited to, overall
volume/number of claims processed and variance account balance.
Variance account balances may earn interest, and interest is earned at the
federal funds or similar rate. Host Blues may retain interest earned on
funds held in variance accounts.
Note: Participants will not bear any portion of the cost of Value-Based
Programs except when a Host Blue uses either average pricing or actual
pricing to pay providers under Value-Based Programs.
Care Coordinator Fees
Host Blues may also bill BCBSAZ for Care Coordinator Fees for provider services which we
will pass on to Employer as follows:
1.
PMPM billings; or
2.
Individual claim billings through applicable care coordination codes from the most
current editions of either Current Procedural Terminology (CPT) published by the
American Medical Association (AMA) or Healthcare Common Procedure Coding
System (HCPCS) published by the U.S. Centers for Medicare and Medicaid Services
(CMS).
As part of this Agreement, BCBSAZ and Employer will not impose Participant cost sharing
for Care Coordinator Fees.
Value-Based Programs under Negotiated Arrangements
If BCBSAZ has entered into a Negotiated National Account Arrangement with a Host Blue
to provide Value-Based Programs to Employer’s Participants, BCBSAZ will follow the same
procedures for Value-Based Programs administration and Care Coordination Fees as noted
in the BlueCard Program section.
Exception: For negotiated arrangements, if any, for Value-Based programs to the extent
that BCBSAZ and Employer have agreed to waive Participant cost sharing for Care
Coordinator Fees, such waiver shall be a part of this Agreement.
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D.
Return of Overpayments
Recoveries of overpayments from a Host Blue or its participating and nonparticipating
providers can arise in several ways, including, but not limited to, anti-fraud and abuse
recoveries, audits/healthcare provider/hospital bill audits, credit balance audits, utilization
review refunds and unsolicited refunds. Recovery amounts determined in the ways noted
above will be applied so that corrections will be made, in general, on either a claim-by-claim
or prospective basis. If recovery amounts are passed on a claim-by-claim basis from a Host
Blue to BCBSAZ they will be credited to Employer’s account. In some cases, the Host Blue
will engage a third party to assist in identification or collection of overpayments. The fees
of such a third party may be charged to Employer as a percentage of the recovery.
Unless otherwise agreed to by the Host Blue, for retroactive cancellations of membership,
BCBSAZ will request the Host Blue to provide full refunds from participating healthcare
providers for a period of only one year after the date of the Inter-Plan financial settlement
process for the original claim. For Care Coordinator Fees associated with Value-Based
Programs, BCBSAZ will request such refunds for a period of only up to ninety (90) days
from the termination notice transaction on the payment innovations delivery platform. In
some cases, recovery of claim payments associated with a retroactive cancellation may not
be possible if, as an example, the recovery (a) conflicts with the Host Blue’s state law or
healthcare provider contracts, (b) would result from Shared Savings and/or Provider
Incentive arrangements or (c) would jeopardize the Host Blue’s relationship with its
participating healthcare providers, notwithstanding to the contrary any other provision of
this Agreement.
E.
Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees
In some instances federal or state laws or regulations may impose a surcharge, tax or other
fee that applies to self-funded accounts. If applicable, BCBSAZ will disclose any such
surcharge, tax or other fee to Employer, which will be Employer’s liability.
F.
Nonparticipating Providers Outside BCBSAZ’s Service Area
1.
Participant Liability Calculation
a.
In General
When Covered Services are provided outside of BCBSAZ’s service area by
nonparticipating providers, the amount(s) a Participant pays for such
services will be based on either the Host Blue’s nonparticipating healthcare
provider local payment or the pricing arrangements required by applicable
state law. In these situations, the Participant may be responsible for the
difference between the amount that the nonparticipating provider bills and
the payment will make for the covered services as set forth in this paragraph.
Payments for out-of-network emergency services will be governed by
applicable federal and state law.
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b.
Exceptions
In some exception cases, BCBSAZ may pay claims from nonparticipating
healthcare providers outside of BCBSAZ’s service area based on the
provider’s billed charge. This may occur in situations where a Participant did
not have reasonable access to a participating provider, as determined by
BCBSAZ in BCBSAZ’s sole and absolute discretion or by applicable state law.
In other exception cases. BCBSAZ may pay such claims based on the
payment BCBSAZ would make if BCBSAZ were paying a nonparticipating
provider inside of BCBSAZ’s service area, as described elsewhere in this
Agreement. This may occur where the Host Blue’s corresponding payment
would be more than BCBSAZ in-service area nonparticipating provider
payment. BCBSAZ may choose to negotiate a payment with such a provider
on an exception basis.
Unless otherwise stated, in any of these exception situations, the Participant
may be responsible for the difference between the amount that the
nonparticipating healthcare provider bills and the payment will make for the
covered services as set forth in this paragraph.
2.
Fees and Compensation
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under applicable Inter-Plan Arrangement
requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-
Plan Arrangement-related services. The specific fees and compensation that are
charged to Employer are set forth in Administrative Service Agreement, Caveat. Fees
and compensation under applicable Inter-Plan Arrangements may be revised from
time to time as provided for in section I.H below.
G.
Blue Cross Blue Shield Global Care
1.
General Information
If Participants are outside the United States (hereinafter: “BlueCard service area”),
they may be able to take advantage of the BCBS Global Core when accessing
Covered Services. BCBS Global Core is unlike the BlueCard Program available in the
BlueCard service area in certain ways. For instance, although BCBS Global Core
assists Participants with accessing a network of inpatient, outpatient and
professional providers, the network is not served by a Host Blue. As such, when
Participants receive care from providers outside the BlueCard service area, the
Participants will typically have to pay the providers and submit the claims
themselves to obtain reimbursement for these services.
□
Inpatient Services
In most cases, if Participants contact the BCBS Global Core Service Center for
assistance, hospitals will not require Participants to pay for covered inpatient
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services, except for their cost-share amounts. In such cases, the hospital will
submit Participant claims to the service center to initiate claims processing.
However, if the Participant paid in full at the time of service, the Participant
must submit a claim to obtain reimbursement for Covered Services.
Participants must contact BCBSAZ to obtain precertification for non-
emergency inpatient services.
□
Outpatient Services
Physicians, urgent care centers and other outpatient providers located
outside the BlueCard service area will typically require Participants to pay in
full at the time of service. Participants must submit a claim to obtain
reimbursement for Covered Services.
□
Submitting a BCBS Global Core Claim
When Participants pay for Covered Services outside the BlueCard service
area, they must submit a claim to obtain reimbursement. For institutional
and professional claims, Participants should complete a BCBS Global Core
claim form and send the claim form with the provider’s itemized bill(s) to the
service center address on the form to initiate claims processing. The claim
form is available from BCBSAZ, the service center, or online at
www.bcbsglobalcore.com. If Participants need assistance with their claim
submissions, they should call the service center at 1.800.810.BLUE (2583) or
call collect at 1.804.673.1177, 24 hours a day, seven days a week.
2.
Blue Cross Blue Shield Global Core Related Fees
Employer understands and agrees to reimburse BCBSAZ for certain fees and
compensation which BCBSAZ is obligated under applicable Inter-Plan Arrangement
requirements to pay to the Host Blues, to the Association and/or to vendors of Inter-
Plan Arrangement-related services. The specific fees and compensation that are
charged to Employer under BCBS Global Core are set forth in Administrative Service
Agreement, Caveat. Fees and compensation under applicable Inter-Plan
Arrangements may be revised from time to time as provided for in section I.H
below.
H.
Modifications or Changes to Inter-Plan Arrangement Fees or Compensation
Modifications or changes to Inter-Plan Arrangement fees are generally made effective Jan.
1 of the calendar year, but they may occur at any time during the year. In the case of any
such modifications or changes, BCBSAZ shall provide Employer with at least thirty (30) days’
advance written notice of any modification or change to such Inter-Plan Arrangement fees
or compensation describing the change and the effective date thereof and Employer right
to terminate this Agreement without penalty by giving written notice of termination before
the effective date of the change. If Employer fails to respond to the notice and does not
terminate this Agreement during the notice period, Employer will be deemed to have
approved the proposed changes, and BCBSAZ will then allow such modifications to become
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part of this Agreement.
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Exhibit G 2
Attachment A to Administrative Services Agreement
A.
Administrative Services Provided By BCBSAZ
1.
Booklets, Identification Cards and Certificates. BCBSAZ shall provide Benefit Plan Booklets
and identification cards to employees unless Employer directs otherwise. BCBSAZ shall
issue Certificates of Creditable Coverage, as may be required by law, for the coverage
administered by BCBSAZ.
2.
Claims Services. BCBSAZ shall receive claims and process payment of benefits in
accordance with the Plan for all claims incurred during the Term and determine benefits
payable under the Plan pursuant to the terms and conditions of the Benefit Plan Booklet,
incorporated by reference into this Agreement. BCBSAZ provides administrative claims
payment services only and does not assume any financial risk or obligation with respect to
claims or the Plan. BCBSAZ will provide notice to Participants regarding the reason(s) for
denials of benefits and provide to Participants an explanation of benefits resulting from
claim transactions. BCBSAZ shall use reasonable efforts to pay ninety percent (90%) of
non-investigated claims (no precertification or additional information needed) that are
locally processed (received and paid by BCBSAZ) within fourteen (14) calendar days of
receipt by BCBSAZ, and pay ninety-nine percent (99%) of non- investigated claims that are
locally processed within thirty (30) calendar days of the date of receipt by BCBSAZ.
3.
Access to Provider Network. BCBSAZ shall provide Participants access to a network or
networks of Providers. BCBSAZ reserves the right to change Network Providers at any time
without notice to Employer, Plan or Participants. Network Providers will accept the BCBSAZ
Allowed Amount as the only payment for Covered Services required from and on behalf of
Participants except that they may collect the difference between their billed charge and the
BCBSAZ Allowed Amount when there is compensation for Covered Services from other
sources (e.g., other insurers, government payors, or personal injury recovery), so long as
permitted by law.
4.
Appeals and Grievances. BCBSAZ shall provide the appeals and grievance services
described in the Health Coverage Appeals Information Packet.
5.
Coordination of Benefits. BCBSAZ will cooperate with Plan to coordinate benefits in
accordance with the Benefit Plan Booklet and applicable state and federal law if services
to which Participants are entitled under the Plan and this Agreement are also covered
under any other group health coverage, Medicare, or other governmental health care
benefit programs (except those provided under Medicaid and/or AHCCCS).
6.
Form 5500. Upon Employer’s request, BCBSAZ will furnish information related to BCBSAZ’s
administration of the Plan and reasonably necessary for Employer to complete the Form
5500 and other similar Plan reports required by a state or federal authority from the
Employer as the Plan Administrator.
7.
HIPAA Privacy Notice. Unless directed otherwise, BCBSAZ will distribute a HIPAA Notice of
Privacy Practices which addresses BCBSAZ’s handling of Participant Protected Health
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Information.
B.
Duties and Authority of Employer
1.
Furnish Plan Information. Employer shall provide, and cause each of its contracted
vendors to provide, timely and accurate information as may be required by BCBSAZ to
perform its duties under this Agreement including, but not limited to:
a.
Eligibility information (including any eligibility changes within 31 days of the date of
such change and COBRA eligibility, if applicable);
Benefit counter or other data for any benefit or coverage Employer has an entity
other than BCBSAZ administer;
b.
Prior written notice of any change to its contribution rates;
c.
Any Participant consent or authorization required for BCBSAZ to perform its duties
under this Agreement; and
d.
Thirty (30) days prior written notice of any change in the Employer’s physical
location, mailing address, state of incorporation, or state in which Employer is
headquartered. Employer acknowledges and agrees that BCBSAZ may rely on the
information provided by Employer or its designee, and Employer agrees to
indemnify, defend and hold BCBSAZ harmless from any liability resulting from
inaccurate or untimely information provided to BCBSAZ by the Employer or its
designee. Additionally, Employer is responsible for claims errors arising from
erroneous eligibility data or inaccurate or untimely data submitted by the Employer
or by a third party retained by the Employer. If timely notice regarding an eligibility
change is not received, a Participant’s coverage termination will be the 1st day of
the month following BCBSAZ’s receipt of written notice.
2.
Notices to Participants. The Employer shall (a) notify Participants of any conversion
privilege set forth in the Benefit Plan Booklet(s); (b) notify all Participants when this
Agreement terminates that their coverage has terminated, provided however, that
coverage will terminate even if such notice is not given by the Employer; and (c) distribute
all notices from BCBSAZ to Participants and comply with federal and state disclosure and
notice laws.
3.
Employer Acknowledgments. Employer acknowledges and agrees that a Benefit Plan
Booklet is not a Summary Plan Description and this Agreement is not a plan document for
purposes of ERISA. In the event of any conflict between the Summary Plan Description and
the Benefit Plan Booklet, the terms of the Benefit Plan Booklet shall control BCBSAZ's
performance under this Agreement. Employer acknowledges that an “employee welfare
benefit plan” as defined in ERISA must be established and maintained through a separate
plan document.
4.
Medicare. Employer will forward to BCBSAZ the information identified and described
below to permit BCBSAZ to fulfill its Medicare secondary payer reporting obligations to the
Centers for Medicare & Medicaid Services or its delegate:
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a.
No later than thirty (30) days after: (i) the date the Participant's coverage first
becomes effective, (ii) the date a new Participant is hired and (iii) the date the
Employer is notified of a new Eligible Dependent, provide BCBSAZ with the following
information for each Participant and Eligible Dependent: (a) Social Security Number,
(b) Date of Birth, (c) Medicare identification number (HICN) if applicable, and (d)
Medicare effective date, if applicable.
b.
No later than thirty (30) days after a Participant's effective date of coverage, provide
BCBSAZ with a list of all Participants who are enrolled in Medicare or who are
Medicare eligible;
c.
No later than three (3) business days after learning that a Participant who was not
enrolled in Medicare or who was not Medicare eligible has now enrolled in Medicare
or become eligible for Medicare, Employer shall notify BCBSAZ in writing of the
Participant's enrollment or eligibility.
d.
No later than three (3) business days after learning that a Participant who was
enrolled in Medicare has now terminated Medicare, Employer shall provide BCBSAZ
written notice of the Participant's Medicare termination.
e.
The Employer shall forward any notification received with regard to Medicare
secondary payer reporting or collections thereunder no later than five (5) days after
receipt.
f.
Employer shall indemnify and hold harmless BCBSAZ for any and all penalties
assessed against BCBSAZ for failure to timely provide regulators with the Medicare,
Medicare related and other information stated in this section to the extent that such
failure was caused by Employer's failure to timely provide BCBSAZ with the written
notice required by this section.
5.
Medicaid. Employer acknowledges that state Medicaid agencies, including
AHCCCS (collectively referred to as “Medicaid Agencies”) are considered payers of
last resort for the claims of Participants who are also Medicaid beneficiaries
("Medicaid Beneficiaries"). Employer further acknowledges that AHCCCS does, and
other state Medicaid Agencies may, have a legal right to reimbursement of
expenditures that the Medicaid Agencies have made on behalf of Medicaid
Beneficiaries, not to exceed the lesser of the Participant's benefits under this plan
or the Medicaid Agencies’ payment on behalf of the Participant. The Plan agrees
that BCBSAZ shall, on the Plan's behalf and as legally required, share data and
reimburse Medicaid Agencies or their designees for the health claims of Participants
who were also Medicaid Beneficiaries on the date of service. The Plan agrees to
promptly reimburse BCBSAZ for such claims.
6.
Enrollment. Employer will provide for and administer any special enrollment
periods as required by applicable law, including the provision of any notification to
employees of any restrictions. The Employer will provide an annual open
enrollment period of at least thirty-one (31) days. The Employer shall provide all
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eligible employees with information regarding the open enrollment period,
including but not limited to the date the open enrollment begins and ends.
C.
Employer’s Financial Responsibility
1.
Claims Invoice. After the close of each month, BCBSAZ will send Employer an ASC Monthly
Claims Invoice which includes payments made in connection with services and supplies
and BCBSAZ’s management of such services and supplies as provided under the Plan.
Such amounts may include, without limitation, the following amounts owed by Employer:
a.
Charges for Covered Services under the Plan;
b.
BlueCard Fees (fees paid to other Blue Plans) which include an "Access Fee"
(generally 4% of claims savings not to exceed $2,000 per Claim) and an
administrative expense "Allowed Amount" ("AEA") (generally $5.00 per physician
claim and $11.00 per hospital claim). The Access Fee and AEA are passed through
as a Claims expense. The BlueCard Fees also include other fees, paid by BCBSAZ to
the Association for the BlueCard Program, including a "Central Financial Agency
Fee" (charged by Claim), an "ITS Transaction Fee" (charged by Claim), 800 toll-free
number fees, and Provider directory fees that are not directly passed through as a
Claims expense but affect BCBSAZ's administrative expenses. BlueCard Fees may
be changed from time to time in accordance with the Association’s processes for
changing such fees.
c.
Fees for network access, care coordination and capitation payments;
d.
Value Based Programs (VBPs) Fees. VBP is outcome-based payment arrangement
and/or a coordinated care model facilitated with one or more local providers that is
evaluated against cost and quality metrics/factors and is reflected in provider
payment. BCBSAZ pays some of its contracted medical providers an amount to
manage the medical care of members diagnosed with certain medical conditions if
the provider demonstrates to BCBSAZ it has satisfied BCBSAZ's criteria for
effectively managing the care ("Value Based Services"). With respect to Participants
residing and receiving Value Based Services in Arizona under a BCBSAZ value based
program, BCBSAZ will generally estimate on an aggregate basis at the beginning of
the contract year the amount BCBSAZ projects it will pay BCBSAZ's contracted
providers for members who receive Value Based Services throughout the upcoming
year in the form of a PMPM or PEPM charge and include this in the ASC Monthly
Claims Invoice. Because amounts are estimates, there may be positive or negative
differences based on actual experience, and such differences will be accounted for
in a variance account maintained by BCBSAZ until the end of the applicable Value-
Based Program payment and/or reconciliation measurement period. The amounts
needed to fund a VBP may be hanged before the end of the measurement period if
it is determined that amounts being collected are projected to exceed the amount
necessary to fund the program or if they are projected to be insufficient to fund the
program. On an aggregate basis for the entire VBP, at the end of the VBP payment
and/or reconciliation measurement period for these arrangements, BCBSAZ may
do one of the following: (a) use any surplus in funds in the variance account to fund
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VBP payments or reconciliation amounts in the next measurement period; or (b)
address any deficit in funds in the variance account through an adjustment to the
PMPM or PEPM billing amount or the reconciliation billing amount for the next
measurement period. If Employer terminates its BCBSAZ contract, Employer will
neither receive a refund nor incur a charge to reflect any variance between what
BCBSAZ charged the Employer in Value Based Charges and what BCBSAZ paid the
providers for Value Based Services. Value Based Services will also apply to your
members who reside in other states/geographical locations served by other Blue
Cross Blue Shield Plans.
The Plan or Employer shall pay the entire ASC Monthly Claims Invoice amount within fifteen (15)
business days of the invoice date in United States funds from a United States bank and branch.
2.
Administrative and Other Fees
a.
Administrative Fees. For the services provided by BCBSAZ under this Agreement,
Employer agrees to pay, or cause the Plan to pay, BCBSAZ the administrative fees
as set forth in this Agreement.
b.
Other Fees.
i.
Collection Fees. In some cases, BCBSAZ will engage a third-party to assist in
the identification and collection of overpayments to providers. BCBSAZ may
charge the fees of such a third party to the Employer.
ii.
Taxes and Surcharges. Employer will pay, and reimburse BCBSAZ for, any
taxes, surcharges, licenses and fees levied, if any, by all local, state or federal
authorities in connection with BCBSAZ’s performance of its duties under this
Agreement, excluding BCBSAZ's income taxes and BCBSAZ's own employee
benefits taxes. Additionally, if any state or federal law results in increased
costs or fees to BCBSAZ, BCBSAZ may, at any time, including on a retroactive
basis if the fee or charge has been retroactively imposed on BCBSAZ by
federal or state authorities, increase the fees due from Employer under this
Agreement.
BCBSAZ will invoice the Employer for Administrative Fees and Other Fees on a
monthly basis, and such Administrative Fees and Other Fees will be due and payable
on the first (1st) day of each calendar month or as otherwise stated in the BCBSAZ
invoice. BCBSAZ will apply a grace period of thirty-one (31) days to the payment of
Administrative Fees and Other Fees during which time those may be paid without
BCBSAZ taking further action. The grace period will not apply to any amounts due
in the ASC Monthly Claims Invoice. During the grace period, the Agreement shall
remain in force, and the Plan shall remain liable for any fees and charges that are
or become due. If the Plan fails to pay any Administrative Fees and Other Fees
before the end of the applicable grace period, BCBSAZ may terminate this
Agreement effective on the date on which such fees first became due or at the end
of the grace period. The Plan will remain liable for all Covered Services rendered
to Participants during the grace period, and the Plan agrees to hold BCBSAZ
harmless from all fees, charges, and costs therefore and for Covered Services
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rendered to Participants after the expiration of the grace period.
3.
Post Termination Responsibility. Following expiration or termination if this Agreement,
Employer remains liable for and shall pay all Charges for Covered Services incurred during
the term of this Agreement along with the associated other charges reflected in the ASC
Monthly Claims Invoice and any applicable Administrative Fees and Other Fees.
4.
Employee Contributions. Employer agrees to segregate all funds collected from employees
for payments to BCBSAZ and hold those funds in trust for the benefit of BCBSAZ until paid.
5.
Failure to Pay. In addition to other remedies available to it, if Employer fails to pay any
amount owed BCBSAZ when due, BCBSAZ may:
a.
Assess a late payment charge equal to twelve percent (12%) per annum of the
outstanding balance for which the payment or any portion of the payments is past
due;
b.
If Employer is late with two (2) or more payments in any twelve (12) month period,
assess a late fee of 0.75% on the outstanding balance or any portion of the balance
that is past due;
c.
Suspend processing and payment of Participant claims; and
d.
Terminate this Agreement for non-payment and pursue available remedies.
BCBSAZ may offset any amounts BCBSAZ would otherwise owe the Plan under this
Agreement or under any other agreement against any amounts the Plan fails to timely pay
BCBSAZ under this Agreement. The Employer agrees that BCBSAZ may offset any amounts
BCBSAZ would otherwise owe to the Employer or to any affiliate of the Employer, including
a subsidiary of the Employer, under this Agreement or under any other agreement, against
any amounts the Employer fails to timely pay BCBSAZ under this Agreement.
6.
Adequate Protection.
a.
Types of Adequate Protection. Employer agrees to provide adequate protection to
BCBSAZ as and when requested by BCBSAZ, including but not limited to the following:
i.
In the event of a letter of credit issued in favor of BCBSAZ in such amount as
determined by BCBSAZ to ensure payment of the obligations under this Agreement.
ii.
Establishing an escrow account with a third party for the Employer to deposit such
funds for the exclusive benefit of BCBSAZ as are determined by BCBSAZ to ensure
payment of the obligations under this Agreement and grant BCBSAZ a first position
security interest in the escrow account to secure BCBSAZ’s rights to such funds;
iii.
Provide a cash security deposit in such amount as determined by BCBSAZ to ensure
payment of the obligations under this Agreement to be held in a non-interest
bearing account during the term of the Agreement.
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iv.
In the event of a bankruptcy filing by Employer, Employer agrees that BCBSAZ is
entitled to adequate protection pursuant to 11 U.S.C.§ 363 as follows:
1.
All pre-petition payments owing to BCBSAZ under this Agreement for the
period of 180 days prior to the filing shall be entitled to priority as provided
in 11 U.S.C. § 507(a)(5);
2.
Employer will pay all post-petition amounts owing under the Agreement on
a timely basis and agrees that the failure to maintain such post-petition
obligations current shall constitute sufficient cause to allow BCBSAZ to
terminate the Agreement;
3.
Employer agrees that BCBSAZ is entitled to adequate protection in the form
of a security deposit, letter of credit or escrow account for the exclusive
benefit of BCBSAZ in an amount equal to three (3) months of estimated
Administrative Fees and Covered Services costs under this Agreement to be
held during the bankruptcy proceedings. Employer further agrees that
BCBSAZ may apply such funds to any post-petition obligations owing by
Employer that are not timely made.
4.
Employer agrees that in order to adequately protect the interest of BCBSAZ
in the event Employer seeks to assume this Agreement pursuant to 11 U.S.C.
§ 365, Employer must pay BCBSAZ all outstanding pre-petition amounts
within thirty (30) days of the entry of an order authorizing the assumption of
the Agreement. In addition, Employer agrees to provide, as adequate
protection of future performance, the sum equal to three (3) months of
estimated Administrative Fees and Covered Services costs in the form of a
letter of credit or escrow deposit within ten (10) days after entry of an order
authorizing assumption of this Agreement.
7.
Failure to Timely Provide Adequate Protection. Employer agrees that BCBSAZ may suspend
all services under this Agreement until such time as Employer provides the adequate
protection required herein. If Employer has not provided the required adequate
protection within thirty (30) days of written notice from BCBSAZ, Employer agrees that
cause exists for BCBSAZ to terminate this Agreement or where applicable, that the failure
to provide the adequate protection constitutes “cause” as defined in 11 U.S.C. § 362(d)(1)
to grant BCBSAZ relief from the automatic stay to terminate this Agreement.
D.
Term and Termination
1.
Term and Renewal. The initial term is set forth on Section III of the Services Agreement.
Prior to the end of the term or any renewal term, if BCBSAZ wishes to renew, BCBSAZ will
forward to Employer an offer to renew this Agreement (Administrative Services Agreement
Amendment). If BCBSAZ has not received the signed Administrative Services Agreement
Amendment on or before the last day of the then-current term or renewal term, this
Agreement will terminate as of the last day of the then-current term or renewal term.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
2.
BCBSAZ’s Right to Term. This Agreement may be terminated as provided below:
a.
BCBSAZ’s Termination Right Without Cause: After this Agreement has been in
effect for twelve (12) months, either Party may terminate this Agreement at any
time, without cause, as of the last day of any calendar month by giving sixty (60)
days’ prior written notice to the other Party.
b.
BCBSAZ’s Termination Right For Cause: BCBSAZ may terminate this Agreement
effective immediately in the event of a material breach of the Agreement by the
City but only if the breach is not cured within thirty (30) days after written notice of
the breach is given to the City.
c.
Notwithstanding Paragraph 2(b) above, BCBSAZ may terminate this Agreement
upon the occurrence of any of the following:
(i)
Upon five (5) days’ prior written notice to the City if the City fails to provide
funds necessary to satisfy its liability for payments for Covered Services;
(ii)
The City's insolvency, appointment of a receiver or a trustee for the City,
assignment for the benefit of creditors by the City, or the commencement
of any proceedings under bankruptcy or insolvency laws by or against the
City that continues for sixty (60) days, or the attachment, levy or other
seizure by legal process of any substantial part of the assets of the City, and
such attachment, levy, or seizure is not quashed, stayed, or released within
sixty (60) days of its occurrence;
(iii)
Fraud or misrepresentation by the City;
(iv)
Changes to the Plan which are not accepted by BCBSAZ
3.
Effect of Termination. Upon termination, BCBSAZ shall have no further duties under this
Agreement, except that (a) BCBSAZ shall cause the orderly transfer of records, if any, from
BCBSAZ to the Employer or its designee in a time frame mutually agreed upon, but not to
exceed six (6) months from the date of termination, and (b) for a period of twenty-four (24)
months following the termination of this Agreement (the "Run-Out Period"), BCBSAZ shall
continue to process and pay claims incurred prior to the termination of this Agreement in
accordance with this Agreement, provided the Employer funds such claims and pays the
fees and charges required by this Agreement. Notwithstanding the foregoing, BCBSAZ is
not obligated to continue to process and pay claims during the Run-Out Period if this
Agreement is terminated for cause. Notwithstanding, Employer remains liable for the full
payment of Charges for Covered Services incurred prior to termination of the Agreement
and other amounts reflected in the ASC Monthly Claims Invoice. All the Employer’s
obligations under this Agreement shall remain in effect through the end of the Run-Out
Period. The Employer agrees to reimburse BCBSAZ for any and all amounts BCBSAZ is
required to pay pursuant to this Agreement, including but not limited to any those resulting
from a grievance or appeals or a determination by CMS that Medicare was not primary,
regardless of whether BCBSAZ is administering claims for the Employer at the time CMS
makes such determination.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F
E.
Miscellaneous. For purposes of this Agreement, references to Employer shall be
construed to mean a Trust or Tribe when applicable based upon the legal structure of the
entity entering in into this Agreement with BCBSAZ.
DocuSign Envelope ID: 3A4A34F7-5DE3-4B22-BE7E-A46FEC9A229F