Allied. In the event Employer’s Administrator is Allied, then NGBS shall provide Employer the following administrative services with regard to the Plan: A. Establishment of certain network arrangements with health care providers that agree to provide services covered under the Plan to participants at a negotiated rate (“Network Services Arrangements”). 1. NGBS and/or its designee shall have the sole discretion as to which Network Services Arrangement (both primary and passive or ancillary) will be available for access by Plan. 2. NGBS shall pay the network access fee required under any such Network Services Arrangement. 3. Providers participating in the network may change at any time without notice to Employer. NGBS will provide Employer with continuing access to provider information to assist covered persons in locating network providers. NGBS or its designee will update the provider information to reflect changes as soon as reasonably possible. Network providers are not employees, agents, or partners of NGBS or its designee. Network providers participate in the Provider Network only as independent contractors. 4. Network providers and Plan participants are solely responsible for any healthcare services rendered to the Plan participants. Neither NGBS, nor its designee, make any representations regarding the value or cost effectiveness of any provider network adopted by Employer. 5. Employer acknowledges that each provider network is solely responsible for: its own provider credentialing, contracting with providers, recruiting, licensing, accreditation, maintaining adequate staffing, practice and professional standards, and all other activities pertinent to the responsibilities accorded provider networks. Access to a selected provider network is at all times conditioned upon Employer’s compliance with applicable network rules, including without limitation, the timely funding of claims at the network provider’s contracted rate. 6. If Employer has elected to utilize the Aetna Signature Administrators ® program as its Network Services Arrangement, Employer agrees to comply with all terms of the Network Services Agreement by and between NGBS and Aetna Life Insurance Company, as may be amended from time to time. B. NGBS or its designee shall provide out of network pricing and negotiation services, which may include but is not limited to the negotiations with providers to obtain discounts on claims that meet the appropriate criteria as determined by the Plan. Employer agrees to immediately fund the payment of any claim which has been negotiated through these services when necessary to secure the discount. Employer understands and agrees that: (a) any such negotiated claim which is not funded in a timely manner may lose the negotiated discount, (b) Employer may be responsible for the applicable fee associated with such negotiation services if the discount is lost, and (c) NGBS will not be responsible for the loss of such a negotiated discount. C. NGBS and/or its health management vendor (for purposes of this section, hereinafter referred to as “Designee”) shall be solely responsible for the provision of all health management and utilization management services as they relate to the Plan. Without limiting the foregoing, this includes all stages of health management, including utilization management and case management, and may include disease management as determined appropriate by NGBS. NGBS shall investigate those claims referred by Employer or the Administrator that require a clinical determination. NGBS, or its Designee, will provide professionals with appropriate credentials to make such determinations. NGBS and/or its Designee shall issue a determination to the Participant and/or providers in the manner and within the time frame set by applicable law, provide the appropriate notice of any additional appeal rights, and administer all appeal levels related to such determinations. 1. If denial is upheld in the second level of appeal, NGBS, or its designee, will determine if the appeal is eligible for external review by an Independent Review Organization (“IRO”). If the appeal is eligible for review by an IRO, then NGBS, or its agent, will inform the participant of such right to appeal to the IRO. D. NGBS, or its designee, shall provide pharmacy benefit management services with regard to the Plan. Any and all reimbursements, rebates or other monies received by NGBS in connection therewith shall be the property of NGBS. E. NGBS will assist Employer and/or Administrator in the creation of the Summary of Benefits and Coverage (“SBC”) for the Plan in accordance with 26 CFR § 54.9815-2715 and 29 CFR §2590.715-2715 and subsequent related federal guidance. Employer will remain responsible for the distribution of the SBC in accordance with federal law.
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Allied. In the event Employer’s Administrator is Allied, then NGBS shall provide Employer the following administrative services with regard to the Plan:
A. Establishment of certain network arrangements with health care providers that agree to provide services covered under the Plan to participants at a negotiated rate (“Network Services Arrangements”).
1. NGBS and/or its designee shall have the sole discretion as to which Network Services Arrangement (both primary and passive or ancillary) will be available for access by Plan.
2. NGBS shall pay the network access fee required under any such Network Services Arrangement.
3. Providers participating in the network may change at any time without notice to Employer. NGBS will provide Employer with continuing access to provider information to assist covered persons in locating network providers. NGBS or its designee will update the provider information to reflect changes as soon as reasonably possible. Network providers are not employees, agents, or partners of NGBS or its designee. Network providers participate in the Provider Network only as independent contractors.
4. Network providers and Plan participants are solely responsible for any healthcare services rendered to the Plan participants. Neither NGBS, nor its designee, make any representations regarding the value or cost effectiveness of any provider network adopted by Employer.
5. Employer acknowledges that each the provider network is solely responsible for: its own provider credentialing, contracting with providers, recruiting, licensing, accreditation, maintaining adequate staffing, practice and professional standards, and all other activities pertinent to the responsibilities accorded provider networks. Access to a selected provider network is at all times conditioned upon Employer’s compliance with applicable network rules, including without limitation, the timely funding of claims at the network provider’s contracted rate.
6. If Employer has elected to utilize the Aetna Signature Administrators ® program as its Network Services Arrangement, Employer agrees to comply with all terms of the Network Services Agreement by and between NGBS and Aetna Life Insurance Company, as may be amended from time to time.
B. NGBS or its designee shall provide out of network pricing and negotiation services, which may include but is not limited to the negotiations with providers to obtain discounts on claims that meet the appropriate criteria as determined by the Plan. Employer agrees to immediately fund the payment of any claim which has been negotiated through these services when necessary to secure the discount. Employer understands and agrees that: (a) any such negotiated claim which is not funded in a timely manner may lose the negotiated discount, (b) Employer may be responsible for the applicable fee associated with such negotiation services if the discount is lost, and (c) NGBS will not be responsible for the loss of such a negotiated discount.
C. NGBS and/or its health management vendor (for purposes of this section, hereinafter referred to as “Designee”) shall be solely responsible for the provision of all health management and utilization management services as they relate to the Plan. Without limiting the foregoing, this includes all stages of health management, including utilization management and case management, and may include disease management as determined appropriate by NGBS. NGBS shall investigate those claims referred by Employer or the Administrator that require a clinical determination. NGBS, or its Designee, will provide professionals with appropriate credentials to make such determinations. NGBS and/or its Designee shall issue a determination to the Participant and/or providers in the manner and within the time frame set by applicable law, provide the appropriate notice of any additional appeal rights, and administer all appeal levels related to such determinations.
1. If denial is upheld in the second level of appeal, NGBS, or its designee, will determine if the appeal is eligible for external review by an Independent Review Organization (“IRO”). If the appeal is eligible for review by an IRO, then NGBS, or its agent, will inform the participant of such right to appeal to the IRO.
D. NGBS, or its designee, shall provide pharmacy benefit management services with regard to the Plan. Any and all reimbursements, rebates or other monies received by NGBS in connection therewith shall be the property of NGBS.
E. NGBS will assist Employer and/or Administrator in the creation of the Summary of Benefits and Coverage (“SBC”) for the Plan in accordance with 26 CFR § 54.9815-2715 and 29 CFR §2590.715-2715 and subsequent related federal guidance. Employer will remain responsible for the distribution of the SBC in accordance with federal law.
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