Page 85 - Aegion PPO SPDs
P. 85
Circumstances Beyond the Control of the Plan
The Claims Administrator shall make a good-faith effort to arrange for an alternative method of
administering benefits. In the event of circumstances not within the control of the Claims Administrator or
Employer, including but not limited to: a major disaster, epidemic, the complete or partial destruction of
Facilities, riot, civil insurrection, labor disputes not within the control of the Claims Administrator, disability
of a significant part of a Network Provider’s personnel or similar causes, or the rendering of health care
services provided by the Plan is delayed or rendered impractical the Claims Administrator shall make a
good-faith effort to arrange for an alternative method of administering benefits. In such event, the Claims
Administrator and Network Providers shall administer and render services under the Plan insofar as
practical, and according to their best judgment; but the Claims Administrator and Network Providers shall
incur no liability or obligation for delay, or failure to administer or arrange for services if such failure or delay
is caused by such an event.
Protected Health Information under HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Privacy Regulations
issued under HIPAA, contain provisions designed to protect the privacy of certain individually identifiable
health information. Your Employer's Group Health Plan has a responsibility under the HIPAA Privacy
Regulations to provide You with a Notice of Privacy Practices. This notice sets forth the Employer's rules
regarding the disclosure of Your information and details about a number of individual rights You have under
the Privacy Regulations. As an Claims Administrator of Your Employer's Plan, Anthem has also adopted
a number of privacy practices and has described those in its Privacy Notice. If You would like a copy of
Anthem's Notice, contact the Member Services number on the back of Your Identification Card.
Medical Policy and Technology Assessment
The Claims Administrator reviews and evaluates new technology according to its technology evaluation
criteria developed by its medical directors. Technology assessment criteria are used to determine the
Experimental / Investigational status or Medical Necessity of new technology. Guidance and external
validation of the Claims Administrator’s medical policy is provided by the Medical Policy and Technology
Assessment Committee (MPTAC) which consists of approximately 20 Doctors from various medical
specialties including the Claims Administrator’s medical directors, Doctors in academic medicine and
Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Payment Innovation Programs
The Claims Administrator pays Network Providers through various types of contractual
arrangements. Some of these arrangements – Payment Innovation Programs (Program(s)) – may include
financial incentives to help improve quality of care and promote the delivery of health care services in a
cost-efficient manner.
These Programs may vary in methodology and subject area of focus and may be modified by the Claims
Administrator from time to time, but they will be generally designed to tie a certain portion of a Network
Provider’s total compensation to pre-defined quality, cost, efficiency or service standards or metrics. In
some instances, Network Providers may be required to make payment to the Claims Administrator under
the Program as a consequence of failing to meet these pre-defined standards.
The Programs are not intended to affect Your access to health care. The Program payments are not made
as payment for specific Covered Services provided to You, but instead, are based on the Network Provider’s
achievement of these pre-defined standards. You are not responsible for any Copayment or Coinsurance
amounts related to payments made by or to the Claims Administrator under the Program(s), and You do
not share in any payments made by Network Providers to the Claims Administrator under the Program(s).
85
The Claims Administrator shall make a good-faith effort to arrange for an alternative method of
administering benefits. In the event of circumstances not within the control of the Claims Administrator or
Employer, including but not limited to: a major disaster, epidemic, the complete or partial destruction of
Facilities, riot, civil insurrection, labor disputes not within the control of the Claims Administrator, disability
of a significant part of a Network Provider’s personnel or similar causes, or the rendering of health care
services provided by the Plan is delayed or rendered impractical the Claims Administrator shall make a
good-faith effort to arrange for an alternative method of administering benefits. In such event, the Claims
Administrator and Network Providers shall administer and render services under the Plan insofar as
practical, and according to their best judgment; but the Claims Administrator and Network Providers shall
incur no liability or obligation for delay, or failure to administer or arrange for services if such failure or delay
is caused by such an event.
Protected Health Information under HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Privacy Regulations
issued under HIPAA, contain provisions designed to protect the privacy of certain individually identifiable
health information. Your Employer's Group Health Plan has a responsibility under the HIPAA Privacy
Regulations to provide You with a Notice of Privacy Practices. This notice sets forth the Employer's rules
regarding the disclosure of Your information and details about a number of individual rights You have under
the Privacy Regulations. As an Claims Administrator of Your Employer's Plan, Anthem has also adopted
a number of privacy practices and has described those in its Privacy Notice. If You would like a copy of
Anthem's Notice, contact the Member Services number on the back of Your Identification Card.
Medical Policy and Technology Assessment
The Claims Administrator reviews and evaluates new technology according to its technology evaluation
criteria developed by its medical directors. Technology assessment criteria are used to determine the
Experimental / Investigational status or Medical Necessity of new technology. Guidance and external
validation of the Claims Administrator’s medical policy is provided by the Medical Policy and Technology
Assessment Committee (MPTAC) which consists of approximately 20 Doctors from various medical
specialties including the Claims Administrator’s medical directors, Doctors in academic medicine and
Doctors in private practice.
Conclusions made are incorporated into medical policy used to establish decision protocols for particular
diseases or treatments and applied to Medical Necessity criteria used to determine whether a procedure,
service, supply or equipment is covered.
Payment Innovation Programs
The Claims Administrator pays Network Providers through various types of contractual
arrangements. Some of these arrangements – Payment Innovation Programs (Program(s)) – may include
financial incentives to help improve quality of care and promote the delivery of health care services in a
cost-efficient manner.
These Programs may vary in methodology and subject area of focus and may be modified by the Claims
Administrator from time to time, but they will be generally designed to tie a certain portion of a Network
Provider’s total compensation to pre-defined quality, cost, efficiency or service standards or metrics. In
some instances, Network Providers may be required to make payment to the Claims Administrator under
the Program as a consequence of failing to meet these pre-defined standards.
The Programs are not intended to affect Your access to health care. The Program payments are not made
as payment for specific Covered Services provided to You, but instead, are based on the Network Provider’s
achievement of these pre-defined standards. You are not responsible for any Copayment or Coinsurance
amounts related to payments made by or to the Claims Administrator under the Program(s), and You do
not share in any payments made by Network Providers to the Claims Administrator under the Program(s).
85
