Page 9 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Claims Administrator and Plan Sponsor

Responsibilities

Determine Benefits

Plan Sponsor and the Claims Administrator make administrative decisions regarding whether the Plan will
pay for any portion of the cost of a health care service you intend to receive or have received. Plan
Sponsor's and the Claims Administrator's decisions are for payment purposes only. Plan Sponsor and the
Claims Administrator do not make decisions about the kind of care you should or should not receive. You
and your providers must make those treatment decisions.
Plan Sponsor and the Claims Administrator have the discretion to do the following:

• Interpret Benefits and the other terms, limitations and exclusions set out in this SPD, the Schedule
of Benefits and any SMMs and/or Amendments.

• Make factual determinations relating to Benefits.
Plan Sponsor and the Claims Administrator may assign this discretionary authority to other persons or
entities including Claims Administrator’s affiliates that may provide administrative services for the Plan,
such as claims processing. The identity of the service providers and the nature of their services may be
changed from time to time in Plan Sponsor's and the Claims Administrator's discretion. In order to receive
Benefits, you must cooperate with those service providers.

Process Payment for the Plan's Portion of the Cost of Covered Health
Care Services

The Claims Administrator processes the Plan's payment of Benefits for Covered Health Care Services as
described in Section 1: Covered Health Care Services and in the Schedule of Benefits, unless the service
is excluded in Section 2: Exclusions and Limitations. This means the Claims Administrator processes only
the payment of the Plan's portion of the cost of Covered Health Care Services. It also means that not all
of the health care services you receive may be paid for (in full or in part) by the Plan.

Process Plan Payment to Network Providers
It is the responsibility of Network Physicians and facilities to file for payment from the Plan. When you
receive Covered Health Care Services from Network providers, you do not have to submit a claim to the
Plan.

Process Plan Payment for Covered Health Care Services Provided by
Out-of-Network Providers
In accordance with any state prompt pay requirements, the Claims Administrator processes the Plan's
payment of Benefits after receiving your request for payment that includes all required information. See
Section 5: How to File a Claim.

6 Claims Administrator and Plan Sponsor Responsibilities