Loading...
HomeMy WebLinkAboutC2023-270 - 7/18/2023 - Approved DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 DENTAL EXHIBIT-PG EMPLOYER NAME:CITY OF CORPUS CHRISTI Employer Account Number:242772 Employer Group Number(s):272774 Effective for the Settlement Period beginning October 1,2023,and ending September 30,2024 Effective for the Settlement Period beginning October 1,2024,and ending September 30,2025 Effective for the Settlement Period beginning October 1,2025,and ending September 30,2026 Effective for the Settlement Period beginning October 1,2026,and ending September 30,2027 Effective for the Settlement Period beginning October 1,2027,and ending September 30,2028 Performance guarantees are contingent upon adherence to the terms and conditions of Addendum-PG to which this Exhibit is attached and maintaining an enrollment in the Plan dental benefit coverage administered by Claim Administrator of not less than 2,011 Covered Employees,based on a total of 2,234 contracts.Performance measurement will begin October 1, 2023.Performance Guarantees are measured and settled annually. Percentage SERVICE—Dental Defined Performance Guarantees Performance of the Dental Guarantee Administrative Charge at Risk Claim Claim Turnaround Time-Turnaround time is defined as the number of days it takes to 90.0%-100% 0% Turnaround Time process a claim,beginning with the date the claim is received to the check/EOB date on 0%-89.9% 2% participant filed claims or to the date the claim passes all edits on provider filed claims. The standard is measured as a percent of process-ready claims finalized within 14 calendar days on an Employer specific basis. Claim Processing Accuracy is defined as the percent of claims processed accurately. The level of 97.0%-100% 0% Processing Accuracy performance is based on the results from a random sample audit of all claims processed for 0%-96.9% 2% those customers assigned to the Unit. Claim Financial Accuracy is defined as the percent of dollars paid accurately. The level of 98.0%-100% 0% Financial Accuracy performance is based on the results from a random sample audit of all claims processed for 0%-97.9% 2% those customers assigned to the Unit. Inquiry Resolution Inquiry Resolution-Inquiry resolution is defined as the number of days it takes to resolve a 95.0%-100% 0% participant inquiry,beginning with the date the inquiry is received to the resolution date. All 0%-94.9% 2% written and telephone inquiries will be measured. The standard is measured as a percent processed within 14 calendar days for those customers assigned to the Unit. Abandoned Calls Abandoned calls are defined as calls,calculated over the complete workday,that reach the 0%-3.0% 0% facility and are placed in a queue,but are not answered because the caller hangs up before a 3.1%-100% 2% service representative becomes available. Any calls abandoned or terminated by the caller prior to the Average Speed to Answer number of seconds standard will not be counted as Abandoned Calls. Standard is measured using participant calls for those customers assigned to the Unit City of Corpus Christi 10.2023-9.2028 Dental PG Exhibit v2 Page 1 of 2 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under raaitten agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 Percentage SERVICE—Dental Defined Performance Guarantees Performance of the Dental Guarantee ' Administrative Charge at Risk Average Speed to Answer Average Speed to Answer,calculated over the complete workday,is defined as the time a 0-30 seconds 0% caller spends on hold until a service representative becomes available. Standard is measured 31 seconds or more 2% by determining the average number of seconds the caller spends waiting for a service representative. Standard is measured using participant calls for those customers assigned to the Unit Total Dental 12% IN WITNESS WHEREOF,the parties have executed this Exhibit-PG to remain in effect for the indicated period of time. BLUE CROSS AND BLUE SHIELD OF TEXAS,a Division of CITY OF CORPUS CHRISTI Health Care Service Corporation,a Mutual Legal Reserve Company Res.033101 Authorized By 7/18/2023 Council nocuSsged by, By: Kathy Selck Josh Chronley (f 7Yf Please Print Name Please Print Name T�eJ�e d by: • s i a r� %1 '!]A]]R�M51 RG]tS Title: Vice President&Chief Underwriter Title: AD of Finance & Procurement Rebecca Huerta 11/15/2023 City Secretary Date: August 28,2023 Date: Approved as to Legal from DocuSigned by: esscsan7lseaea_ 11/13/2023 Assistant City Attorney City of Corpus Christi 10.2023-9.2028 Dental PG Exhibit v2 Page 2 of 2 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under w itten agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 EXHIBIT-PG EMPLOYER NAME:CITY OF CORPUS CHRISTI Employer Account Number:242772 Employer Group Number(s):242772 and 272773 Effective for the Settlement Period beginning October 1,2023,and ending September 30,2024 Effective for the Settlement Period beginning October 1,2024,and ending September 30,2025 Effective for the Settlement Period beginning October 1,2025,and ending September 30,2026 Effective for the Settlement Period beginning October 1,2026,and ending September 30,2027 Effective for the Settlement Period beginning October 1,2027,and ending September 30,2028 Performance guarantees are contingent upon adherence to the terms and conditions of Addendum-PG to which this Exhibitis attached and maintaining an enrollment in the Plan medical benefit coverage administered by Claim Administrator of not less than 2,678 Covered Employees based on a total of 2,976 contracts.Performance measurement will begin October 1, 2023. Performance Guarantees are measured and settled annually. Percentage SERVICE—Medical Defined Performance Guarantees ' Performance of the Guarantee ' Administrative Charge at Risk Account Management Account Management means the Employer's satisfaction with Account Management and will Composite Score be measured by the Employer,using the Claim Administrator's Account Management Client 3.0-5.0 0% Satisfaction Survey. 0-2.9 2% Claims Processing Claims Processing Turnaround Time means the period beginning on the date the Claim 90.0%_100% 0% Turnaround Time— Administrator or Host Blue receives a Claim for processing through the date the Claim passes 88.0%-89.9% 1% Process-Ready Claims all system edits and benefits are approved or denied by the Claim Administrator.The 0%-87.9% 2% performance guarantee is measured as a percent of process-ready Claims processed within 14 calendar days. Method of Measurement:The number of process-ready claims processed in 14 calendar days divided by the total number of process-ready claims.Process-ready means a Claim that,when received by the Claim Administrator,contains all of the Claim information required to process the Claim.Measurement is based on Employer-specific Claims. Claims Processing Claims Processing Turnaround Time means the period beginning on the date the Claim 97.0%-100% 0% Turnaround Time—All Administrator or Host Blue Plan receives a Claim for processing through the date the Claim 95.0%-96.9% 1% Claims passes all system edits and benefits are approved or denied by the Claim Administrator.The 0%-94.9% 2% performance guarantee is measured as a percent of all Claims processed within 30 calendar days. Method of Measurement:The number of Claims processed in 30 calendar days divided by the total number of claims.Measurement is based on Employer-specific Claims. City of Corpus Christi 10.2023-9.2028 Medical PPO PG Exhibit v2 Page 1 of 4 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under written agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 Percentage SERVICE—Medical Defined Performance Guarantees ' Performance of the Guarantee Administrative Charge at Risk Claim Processing Claim Processing Accuracy is defined as the percent of Claims processed accurately in 97.0%-100% 0% Accuracy accordance with the provisions of the medical benefit coverage administered by the Claim 95.0%-96.9% 1% Administrator.Claim Processing Accuracy refers to Claims without processing errors such as: 0%-94.9% 2% 1. Coding-incorrect claim data entry. 2. Failure to adhere to the Employer's health care benefit program design. 3. Failure to adhere to the administrative procedures. 4. System generated errors,benefit programming errors,calculation errors. 5. Excluding: a. Any administrative inaccuracies that do not impact claims disposition or customer reporting; b. Errors entered by providers of service; c. Benefits provided to an ineligible claimant due to the Employer's failure to provide timely and accurate eligibility information to the Claim Administrator. Method of measurement:The accuracy rate is determined from a statistically valid random stratified sample audit of all Claims processed during the settlement period. A Claim Processing Accuracy percentage is calculated for each stratum by dividing the number of accurately processed Claims by the number of Claims selected in the stratum. Each accuracy percentage is then weighted according to the total claim population.The Claim Processing Accuracy rate is determined by summing the weighted accuracy from each stratum. Measurement is based on an audit of Claims processed for those customers assigned to the Unit. Claim Financial Accuracy Claim Financial Accuracy means the percent of dollars paid accurately in accordance with 98.0%-100% 0% the provisions of the medical benefit coverage administered by the Claim Administrator. 97.0%-97.9% 1% 0%-96.9% 2% Method of measurement: The accuracy rate is determined from a statistically valid random stratified sample audit of all Claims paid during the Settlement Period.Total dollars overpaid and total dollars underpaid are projected over each stratum.Claim Financial Accuracy is computed by summing the projected overpayments and the projected underpayments(absolute value)from each stratum and dividing by the total dollars paid in the population.The end result is subtracted from one for the accuracy rate.Measurement is based on an audit of Claims processed for those customers assigned to the Unit. City of Corpus Christi 10.2023-9.2028 Medical PPO PG Exhibit v2 Page 2 of 4 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under written agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 Percentage SERVICE—Medical Defined Performance Guarantees ' Performance of the Guarantee Administrative Charge at Risk Customer Service Inquiry Resolution is defined as number of days it takes to resolve a participant inquiry, 95.0%-100% 0% beginning with the date the inquiry is received to the resolution date. All written and telephone 94.0%-94.9% 1% inquiries will be measured. The standard is measured as a percent processed within 14 0%-93.9% 2% calendar days on an Employer-specific basis. Average Speed of Answer of Telephone Calls,calculated over the complete business day,is 0-30 seconds 0% defined as the time a caller spends on hold until a customer advocate becomes available. 31-60 seconds 1% 61 seconds or more 2% Method of measurement:The average speed of answer will be calculated by dividing the total length of time for all calls,measured from the time a call is queued by the automated telephone system for the next available customer advocate until the time the caller is connected with a customer advocate,by the total number of calls connected with a customer advocate during the Settlement Period.The Average Speed to Answer is provided by telephone reports that compute the average number of seconds that Callers spend on hold waiting for their Call to be answered.Standard is measured using member calls on an Employer-specific basis. Abandoned Calls are defined as calls,calculated over the complete business day,that reach 0%-3.0% 0% the facility and are placed in a queue,but are not answered because the caller hangs up before a 3.1%-5.0% 1% customer advocate becomes available. Any calls abandoned or terminated by the caller prior 5.1%-100% 2% to 30 seconds will not be counted as Abandoned Calls. Standard is measured using member calls on an Employer-specific basis. F tal Medical 16% City of Corpus Christi 10.2023-9.2028 Medical PPO PG Exhibit v2 Page 3 of 4 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under written agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 IN WITNESS WHEREOF,the parties have executed this Exhibit-PG to remain in effect for the indicated period of time. BLUE CROSS AND BLUE SHIELD OF TEXAS,a Division of CITY OF CORPUS CHRISTI Health Care Service Corporation,a Mutual Legal Reserve Company �ocuS�ed�� elck Josh Chronley Kathyy Ras.033101 Please Print Name Please Print Name Authorized By 7/18/2023 Council Title: Vice President&Chief Underwriter Title: AD of Finance & Procurement Ds Date: August 28,2023 Date: 11/15/2023 IW-66 AToT SS�ea by, a 7' Approved as to Legal from Rebecca Huerta City Secretary DocuSigned by: 11/13/2023 esscsanrrseaea_ _ t Assistant City Attorney City of Corpus Christi 10.2023-9.2028 Medical PPO PG Exhibit v2 Page 4 of 4 8/28/2023 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third-party representatives,except under written agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 ADDENDUM PG PERFORMANCE GUARANTEES The Performance Guarantees described herein shall apply to the Administrative Services Agreement (the "Agreement")to which this Addendum is attached and have the same force and effect as the Agreement's most current Fee Schedule, unless amended, replaced, or terminated by the parties to the Agreement in writing. All obligations, definitions, terms, conditions, promises, agreements, and language in the Agreement and its most current Fee Schedule apply equally to the obligations, terms, conditions, promises, agreements, and language in this Addendum PG and its most current Exhibit-PG. SECTION I TIMING A. The period for which the Claim Administrator's performance will be measured and for which Employer may receive a refund is referred to as the Settlement Period and is indicated on the most current Exhibit-PG. B. The measurement of Performance Guarantees will begin on the date indicated on the most current Exhibit-PG provided all of the requirements listed below are completed. The requirements are as follows: 1. Benefit information and claims administrative procedures have been provided by Employer to the Claim Administrator, 2. All accumulation totals, if applicable, have been received from the prior carrier and have been loaded onto the Claim Administrator's claims processing system, 3. Accurate and complete membership information has been received and loaded onto the Claim Administrator's claims processing system, and 4. Transfer Payment procedures have been established in accordance with the Agreement. SECTION II DETERMINATION A. The Claim Administrator agrees to guarantee performance levels as indicated on the most current Exhibit-PG. In the event that the Claim Administrator's level of performance is determined to be less than any of the standards described in the most current Exhibit-PG during a Settlement Period for which the Claim Administrator's performance shall be evaluated for any reason, except any disaster or epidemic which substantially disrupts the Claim Administrator's normal business operation, the Claim Administrator will be responsible for reimbursing Employer a portion of the Administrative Charge. B. The Claim Administrator will measure Performance Guarantees and report the measurement results to Employer, and any refund amounts due in accordance with this Page 1 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives, except under written agreement. DocuSign Envelope ID:CD9134BA-EC63-44DF-9449-BAE3B06E2FA1 Addendum PG within 120 days following the close of all measurement periods necessary to finalize Performance Guarantee results for the Settlement Period. C. The Claim Administrator will not be obligated to measure Performance Guarantees and will not be obligated to refund Employer based thereon until the Administrative Services Agreement(including the most current Exhibit-PG) has been executed and is on file with the Claim Administrator by the close of the applicable Settlement Period. D. The Claim Administrator will not be obligated to measure Performance Guarantees and will not be obligated to refund Employer based thereon for any portion of the Settlement Period in which the Employer: 1. Fails to provide the Claim Administrator with Timely changes in enrollment or membership information or any other reports or information as may be necessary for the Claim Administrator to perform its administrative duties, including but not limited to identification or certification of claimants eligible for benefits, dates of eligibility,number of employees and dependents covered under the Plan; or 2. Fails to pay Administrative Charges in accordance with the terms of the Agreement or comply with all established Transfer Payment procedures. E. The Claim Administrator will not be obligated to measure any Performance Guarantee impacted by changes requested in writing by Employer during the time period required to modify the Claim Administrator's system and to complete all other tasks necessary to achieve the same qualitative standard of execution that existed before the change was requested. All changes or amendments to the Plan must be submitted to the Claim Administrator in accordance with the Agreement. F. If for any reason there is a significant change in the benefit structure or the administrative procedures of the benefit coverage administered by the Claim Administrator, Medicare payment systems, or if the enrollment of the Plan's benefit coverage administered by the Claim Administrator varies in number of enrolled Covered Employees as indicated in the most current Exhibit-PG attached to and made a part of this Addendum during any Settlement Period, the Claim Administrator reserves the right to re-evaluate and renegotiate the level of performance and/or the Administrative Charges at risk in this Addendum PG and the attached Exhibit-PG.. G. If for any reason the Agreement is terminated prior to the end of any Settlement Period, the Performance Guarantees will not be measured and Employer will not receive any refund, based on that part of the Settlement Period in which the Administrative Services Agreement was in effect. H. If(i) changes to the formula, methodology or manner in which a third-party benchmark (such as AWP) is calculated or reported take effect, or (ii) such third party ceases to publish such benchmark, then the performance guarantees and/or standards based on such benchmark in this Agreement, if any, shall be re-evaluated and adjusted or converted to an alternative benchmark by Claim Administrator or its designee at the time of such change to return the parties to their respective economic positions with respect to such guarantees and/or standards as they existed under the Agreement immediately prior to such change. Page 2 Proprietary Information Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives, except under written agreement.