Asserta Health Inc 10/18/2018 - Laserfiche WebLink

forth in this Agreement, those powers that shall be agreed in writing from time to time and powers that are reasonably necessary and incidental to so perform its obligations under this Agreement.Asserta shall,during the Term,provide the following services: 2.1. Concierge Services. a. Respond to Member and Health Plan inquiries. Asserta will respond to all telephone calls (during regular business hours of 7:00 a.m.-5:00 p.m.Mountain Time),mail,email or personal inquiries from Members and Health Plan with respect to the benefits, requirements and procedures of the relevant Member,within a reasonable period of time not to exceed 2 business days. b. Provide Member education and informational service. Asserta will validate Members eligibility for benefits with Health Plan or the designated TPA and educate Members about: i. The details of their specific benefit plan, ii. What cash options are available, iii. How their decisions impact their financial responsibility,and iv. What to do in the event they are balanced billed. Subject to the Member's discretion and needs, Asserta will inform and identify for plan members those Providers known to accept the reimbursement specified in the Health Plan's plan documents. Subject to Member approval,Asserta will assist Members in registering for inpatient and outpatient procedures to ensure the correct co-pay is charged to the Member. c. Case Administration i. Provide Member assistance and scheduling—receive inbound calls from Members, explain options and answer questions, schedule appointments with Providers and any required pre-operative testing or evaluation. ii. Negotiate Cash Price relative to Reference Price -negotiate Cash Price with Providers that is at or below the Health Plan's Reference Price stated as percentage of Medicare. iii. Coordinate payment process via medEcash payment platform— educate Member regarding use of medEcash platform,work with Member,Health Plan and/or designated TPA to set up accounts,send funding requests via the medEcash platform, stage funds in platform prior to procedure, monitor payment execution and provide technical support. iv. Coordinate with medical management function to secure pre-authorization(if required)-work with Health Plan's medical management vendor to understand pre-authorization requirements and establish process for working with them on individual cases,request and submit required information including medical records, communicate pre-authorization to Member, Providers and designated TPA,and engage medical management vendor for management of post-operative care if necessary. v. Submit paid claims to designated TPA to create administrative record of care—generate and transmit an 837 or format preferred by designated TPA to document procedure,diagnoses,and price paid for benefit accumulators, plan accounting and reporting purposes within 3 business days after the procedure. 2.2.Reporting.Asserta will provide periodic reporting to Health Plan,as follows: Quarterly: • Register of all Concierge Services and Cash Payment of Non-Contracted Services managed hereunder • Register of medEcash transactions for payment of all Covered Services processed hereunder • Register of all Member financial responsibility payments(e.g. co-pays and deductible and co- insurance payments) to be accumulated toward Participants deductible and out-of-pocket maxima. Other: • Such other services of a similar type to those listed above in this Section 2.2 as may reasonably be requested by Health Plan. -2-