Description of Claim Administration Services Sample Clauses
The "Description of Claim Administration Services" clause defines the specific tasks and responsibilities that a service provider will perform in managing and processing insurance or benefit claims on behalf of a client. This typically includes activities such as receiving and reviewing claims, determining eligibility, communicating with claimants, and issuing payments or denials according to the terms of the relevant policy or plan. By clearly outlining the scope and nature of these services, the clause ensures both parties understand their obligations and helps prevent disputes over what is included in the administration process.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall:
(i) provide claimants under the Reinsured Contract and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(ii) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(iii) review all Claims and determine whether the Claimant is eligible for benefits and if so, the nature and extent of such benefits;
(iv) prepare and distribute to the appropriate recipients any reports required by Applicable Law;
(v) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response; and
(vi) maintain a complaint log with respect to the Reinsured Contracts in accordance with applicable requirements of Governmental Authorities and provide a copy of such log, continuously updated through the last day of each calendar quarter during the term of this Agreement, to the Company on or before the tenth Business Day of each calendar quarter covering changes during the preceding calendar quarter.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall:
(i) provide claimants under the LBL Contracts and Vermont Captive Contracts and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(ii) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(iii) review all Claims and determine whether the Claimant is eligible for benefits and if so, the nature and extent of such benefits;
(iv) prepare and distribute to the appropriate recipients and Governmental Entities any Claims reports as required by Applicable Law;
(v) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response;
(vi) maintain a complaint log with respect to the LBL Contracts and Vermont Captive Contracts in accordance with applicable requirements of Governmental Entities, and at the Company’s request, provide a copy of such log; and
(vii) respond to and manage any Claims-related matters pursuant to Article VII.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall:
(a) provide claimants under the Policies and their authorized Representatives (collectively, “Claimants”) with Claim forms and provide explanatory guidance to Claimants in connection therewith;
(b) receive, review, record and examine all notices or reports of Claims and initiate procedures for the proper servicing of each Claim;
(c) establish, maintain and organize Claim files;
(d) conduct an investigation of each Claim, including identification of any coverage issues arising from the facts or circumstances of the Claim;
(e) adjust and manage each Claim;
(f) prepare and distribute to the appropriate recipients any reports required by Applicable Law;
(g) comply with all Applicable Law applying to claims handling and settlement practices;
(h) respond promptly to all written or oral Claims-related communications from Claimants; and
(i) maintain a complaint log with respect to the Policies in accordance with applicable requirements of Governmental Authorities and, upon the reasonable request of the Company, provide a copy of such log.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall:
(i) provide claimants under the Reinsured Contracts and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(ii) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(iii) review all Claims and determine whether the Claimant is eligible for benefits and if so, the nature and extent of such benefits;
(iv) prepare and distribute to the appropriate recipients and Governmental Entities any Claims reports as required by applicable Law;
(v) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response;
(vi) maintain a complaint log with respect to the Reinsured Contracts in accordance with applicable requirements of Governmental Entities, and at the Company’s request, provide a copy of such log;
(vii) respond to and manage any Claims-related matters pursuant to Article VII; and
(viii) adopt death claim processing procedures that ensure: (a) reasonable and diligent efforts are made to timely locate beneficiaries in accordance with applicable Law, (b) beneficiaries are provided notification in accordance with the applicable state’s unfair claim practice requirements and (c) interest owed on death proceeds is calculated in accordance with the applicable Reinsured Contract and the applicable state’s interest requirements.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall, with respect to business represented by the Reinsured Policies and the Subject Contracts:
(a) provide claimants and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(b) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(c) review all Claims and determine whether the Claimant is eligible for loss payments and if so, the nature and extent of such loss payments;
(d) prepare and distribute to the appropriate recipients and Governmental Authorities any reports required by Applicable Law;
(e) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response; and
(f) respond to and manage any Claims-related matters pursuant to Article VII.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall:
(a) provide claimants under the Administered Contracts and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(b) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(c) review all Claims and determine whether the Claimant is eligible for benefits and if so, the nature and extent of such benefits;
(d) prepare and distribute to the appropriate recipients and Governmental Entities any reports relating to periods following the Closing Date as required by Applicable Law;
(e) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response;
(f) maintain a complaint log with respect to the Administered Contracts in accordance with applicable requirements of Governmental Entities and provide a copy of such log, continuously updated through the last day of each month during the term of this Agreement, to the applicable Company on or before the twentieth (20th) Business Day of each month covering changes during the preceding month; and
(g) respond to and manage any Claims-related matters pursuant to Article VIII.
Description of Claim Administration Services. Without limiting the foregoing, Administrator shall perform the following services in connection with the Claims, as appropriate:
(i) provide claimants and their authorized representatives (collectively, “Claimants”) with claim forms and explanatory guidance as required by Applicable Law;
(ii) establish, maintain and organize claim files and maintain and organize other claims-related records;
(iii) conduct an investigation of each Claim, including the identification of any coverage issues arising from the facts and circumstances of the Claim;
(iv) adjust and manage each Claim;
(v) prepare and distribute to the appropriate recipients any reports required by Applicable Law;
(vi) respond to all written or oral claims-related communications as required by Applicable Law; and
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall, consistent with the past practices of the Company, to the extent such practices are compliant with applicable Law:
(a) provide claimants under the Administered Contracts and their authorized representatives (collectively, “Claimants”), with Claim forms or with access to Claim forms available for download or printing via the Company’s website as allowed by applicable Law, and provide instructions on how to submit a Claim upon request by such Claimants to Claimants in connection therewith;
(b) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(c) receive, process, and evaluate Claims filed by or on behalf of Customers or Contract Holders, determine whether the Claimant is eligible for benefits and if so, the nature and extent of such benefits, and pay such Claims in accordance with the terms and conditions of the Administered Contracts and the Law or propose to deny, in accordance with the terms and conditions of the Administered Contracts and the Law, or deny such Claims in whole or in part;
(d) provide Claimants with written notice of approval or disapproval of Claims and discharging other contractual obligations under the Administered Contracts, including issuances of explanation of benefits and provider remittance advices;
(e) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response or as required by applicable Law;
(f) maintain a record of any appeals and grievances with respect to the Administered Contracts in accordance with applicable requirements of Governmental Entities and provide a copy of such log upon Company’s request; and
(g) comply in all material respects with all applicable Laws of any Governmental Entity related to Claims processing or payment, including prompt pay Laws.
Description of Claim Administration Services. Without limiting the foregoing, Administrator shall perform the following services in connection with the Claims, as appropriate:
(i) provide claimants and their authorized representatives (collectively, “Claimants”) with claim forms and explanatory guidance as required by Applicable Law;
(ii) establish, maintain and organize claim files and maintain and organize other claims-related records;
(iii) conduct an investigation of each Claim, including the identification of any coverage issues arising from the facts and circumstances of the Claim;
(iv) adjust and manage each Claim;
(v) prepare and distribute to the appropriate recipients any reports required by Applicable Law;
(vi) respond to all written or oral claims-related communications as required by Applicable Law; and
(vii) maintain a complaint log with respect to the Claims in accordance with applicable requirements of Governmental Authorities and provide a copy of such log, continuously updated through the last day of each calendar quarter during the term of this Agreement, to Company on or before the thirtieth day of each calendar quarter covering changes during the preceding calendar quarter.
Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall, with respect to business represented by the Policies:
(a) provide claimants and their authorized representatives (collectively, “Claimants”) with Claim forms and provide reasonable explanatory guidance to Claimants in connection therewith;
(b) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(c) review all Claims and determine whether the Claimant is eligible for loss payments and if so, the nature and extent of such loss payments;
(d) prepare and distribute to the appropriate recipients and Governmental Authorities any reports required by Applicable Law;
(e) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a response; and
(f) respond to and manage any Claims-related matters pursuant to Article VII.