Page 88 - Aegion Value Plan SPDs
P. 88
Right of Recovery and Adjustment
Whenever payment has been made in error, the Plan will have the right to recover such payment from You
or, if applicable, the Provider or otherwise make appropriate adjustment to claims. In most instances such
recovery or adjustment activity shall be limited to the calendar year in which the error is discovered
The Claims Administrator has oversight responsibility for compliance with Provider and vendor contracts.
The Claims Administrator may enter into a settlement or compromise regarding enforcement of these
contracts and may retain any recoveries made from a Provider or vendor resulting from these audits if the
return of the overpayment is not feasible. Additionally, The Claims Administrator has established recovery
and adjustment policies to determine which recoveries and adjustments are to be pursued, when to incur
costs and expenses and settle or compromise recovery or adjustment amounts. The Claims Administrator
will not pursue recoveries for overpayments or adjustments for underpayments if the cost of the activity
exceeds the overpayment or underpayment amount.
Important Note
The Employer, on behalf of itself and its members/participants, hereby expressly acknowledges its
understanding that the Administrative Services Agreement (which includes this Benefit Booklet) constitutes
a contract solely between the Employer and Healthy Alliance Life Insurance Company (Anthem), and that
Anthem is an independent corporation licensed to use the Blue Cross and Blue Shield names and marks
in the State of Missouri. The Blue Cross and Blue Shield marks are registered by the Blue Cross and Blue
Shield Association with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries.
Further, Anthem is not contracting as the agent of the Blue Cross and Blue Shield Association or any other
Blue Cross and/or Blue Shield Plan or licensee. This paragraph shall not create any additional obligations
whatsoever on the part of Anthem other than those obligations created under other provisions of the
Administrative Services Agreement or this Benefit Booklet.
Notice
Any notice given under the Plan shall be in writing. The notices shall be sent to: The Employer at its
principal place of business; to You at the Subscriber’s address as it appears on the records or in care of
the Employer.
Modifications
This Benefit Booklet shall be subject to amendment, modification, and termination in accordance with any
of its provisions by the Employer, or by mutual agreement between the Claims Administrator and the
Employer without the consent or concurrence of any Member. By electing medical and hospital benefits
under the Plan or accepting the Plan benefits, all Members legally capable of contracting, and the legal
representatives of all Members incapable of contracting, agree to all terms, conditions, and provisions
hereof.
Conformity with Law
Any provision of the Plan which is in conflict with the applicable federal laws and regulations is hereby
amended to conform with the minimum requirements of such laws.
Clerical Error
Clerical error, whether of the Claims Administrator or the Employer, in keeping any record pertaining to this
coverage will not invalidate coverage otherwise validly in force or continue benefits otherwise validly
terminated.
Policies and Procedures
The Claims Administrator may adopt reasonable policies, procedures, rules and interpretations to promote
the orderly and efficient administration of the Plan with which a Member shall comply.
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Whenever payment has been made in error, the Plan will have the right to recover such payment from You
or, if applicable, the Provider or otherwise make appropriate adjustment to claims. In most instances such
recovery or adjustment activity shall be limited to the calendar year in which the error is discovered
The Claims Administrator has oversight responsibility for compliance with Provider and vendor contracts.
The Claims Administrator may enter into a settlement or compromise regarding enforcement of these
contracts and may retain any recoveries made from a Provider or vendor resulting from these audits if the
return of the overpayment is not feasible. Additionally, The Claims Administrator has established recovery
and adjustment policies to determine which recoveries and adjustments are to be pursued, when to incur
costs and expenses and settle or compromise recovery or adjustment amounts. The Claims Administrator
will not pursue recoveries for overpayments or adjustments for underpayments if the cost of the activity
exceeds the overpayment or underpayment amount.
Important Note
The Employer, on behalf of itself and its members/participants, hereby expressly acknowledges its
understanding that the Administrative Services Agreement (which includes this Benefit Booklet) constitutes
a contract solely between the Employer and Healthy Alliance Life Insurance Company (Anthem), and that
Anthem is an independent corporation licensed to use the Blue Cross and Blue Shield names and marks
in the State of Missouri. The Blue Cross and Blue Shield marks are registered by the Blue Cross and Blue
Shield Association with the U.S. Patent and Trademark Office in Washington, D.C. and in other countries.
Further, Anthem is not contracting as the agent of the Blue Cross and Blue Shield Association or any other
Blue Cross and/or Blue Shield Plan or licensee. This paragraph shall not create any additional obligations
whatsoever on the part of Anthem other than those obligations created under other provisions of the
Administrative Services Agreement or this Benefit Booklet.
Notice
Any notice given under the Plan shall be in writing. The notices shall be sent to: The Employer at its
principal place of business; to You at the Subscriber’s address as it appears on the records or in care of
the Employer.
Modifications
This Benefit Booklet shall be subject to amendment, modification, and termination in accordance with any
of its provisions by the Employer, or by mutual agreement between the Claims Administrator and the
Employer without the consent or concurrence of any Member. By electing medical and hospital benefits
under the Plan or accepting the Plan benefits, all Members legally capable of contracting, and the legal
representatives of all Members incapable of contracting, agree to all terms, conditions, and provisions
hereof.
Conformity with Law
Any provision of the Plan which is in conflict with the applicable federal laws and regulations is hereby
amended to conform with the minimum requirements of such laws.
Clerical Error
Clerical error, whether of the Claims Administrator or the Employer, in keeping any record pertaining to this
coverage will not invalidate coverage otherwise validly in force or continue benefits otherwise validly
terminated.
Policies and Procedures
The Claims Administrator may adopt reasonable policies, procedures, rules and interpretations to promote
the orderly and efficient administration of the Plan with which a Member shall comply.
88
