Corvel Enterprise Comp, Inc. 9/6/2022 Amendment 3

DocuSign Envelope ID:06CEAA47-F11F-421A-B8CE-390F42C61208 II. DELIVERY OF SERVICES OF MEDICARE SET ASIDES a. Customer/Carrier shall provide the CorVel Medicare Set-Aside Hub office with a copy of the first report of injury, most recent two years of medical records and medical bills including indemnity payout,all operative reports, IMEs/AMEs as well as orders rendered by the workers' compensation judicial system. Appropriate releases for completion of request for service will be forwarded either to the Customer or,at the Customer's request, directly to counsel representing the injured worker to obtain the injured worker's signature. b. Customer may submit a request for a Medicare Set-Aside via email, phone, fax, or electronically via CorVel's CareMC website, if applicable. c.A certified Medicare Consultant("Consultant")will review the medical records and bill summary,prepare a detailed summary of the records and a projection for future medical expense which are Medicare eligible. If requested,the Consultant will also provide a projection of those costs which are not Medicare eligible in order to provide the customer with their total medical exposure. d. The Consultant will return the completed Medicare Set-Aside report to the Customer within fifteen(15)business days of receiving all relevant medical records and related information. If a rated age is warranted,the Consultant will acquire same. If the Medicare status of injured party is unknown or unclear,a request for Medicare status will be submitted to the Social Security Administration. Once the Medicare status is known, the Coordination of Benefits Contractor will be notified and conditional payments requested. e. Upon Customer's request,CorVel Medicare Set-Aside Hub office will submit through the web-portal all required documents to enable CMS to review and approve the proposal. Items submitted include the Medicare Set-Aside report,the tentative settlement amount,along with other required documentation,to the Centers for Medicare& Medicaid Services(CMS). Upon receipt, CorVel Medicare Set-Aside Hub office will forward the CMS Determination letter to the Customer. Final executed settlement documents(reflecting CMS recommended Medicare Set-Aside amount)will be provided to CorVel Medicare Set-Aside Hub by the Customer/counsel and then forwarded by CorVel to CMS through the web-portal. f. Upon request from Customer, CorVel shall provide Customer quarterly activity report within twenty(20)business days following the applicable quarter. III. DELIVERY OF SERVICES OF LIFE CARE PLANS/FUTURE COST PROJECTIONS i.Customer shall provide all available medical records and billing to CorVel Medicare Set- Aside Hub office as well as any other pertinent records for initial review. ii.For a Life Care Plan, a visit to the residence of the Customer's employee or injured individual with interview of claimant and family will be conducted after permission is acquired by the Customer. The interview will include evaluation of the home setting, extensive information gathering,and pictures of the various equipment and housing structures. City of Everett,WA—CorVel EC Amendment 3 7-25-2022