Common use of Right to Audit Claims Clause in Contracts

Right to Audit Claims. Client may audit Company’s payment of Plan Benefits in accordance with the following requirements: A. Client shall provide to Company a scope of audit letter and the fully executed Claim Audit Agreement, a sample of which is attached hereto, together with a forty-five (45) day advance written request for audit. B. Client may designate with Company’s consent (which consent shall not to be unreasonably withheld) an independent, third-party auditor to conduct the audit (the “Auditor”). C. Client and Company will agree upon the date for the audit during regular business hours at Company’s office(s). D. Except as otherwise agreed to by the parties in writing prior to the commencement of the audit, the audit shall be conducted in accordance with the terms of Company’s Claim Audit Agreement attached hereto as “Claim Audit Agreement”, which is hereby agreed to by Client and which shall be signed by the Auditor prior to the start of the audit. E. If the audit identifies any claim adjustments, such adjustments will be made in accordance with this Agreement and based upon the actual claims reviewed and not upon statistical projections or extrapolations. F. Client shall be responsible for its Auditor’s costs. Client may (as determined by Company based upon the resources required by the audit requested) be responsible for Company’s reasonable costs with respect to the audit, except that while this Agreement is in effect there shall be no additional cost to Client for an audit of payment documents relating to a random, statistically valid sample of two-hundred twenty-five (225) claims paid during the two prior Plan years and not previously audited, provided that if Client has five thousand (5,000) or more employees who are Members, Client may conduct one such audit every Plan Year (but not within six (6) months of a prior audit); otherwise, Client ay conduct one such audit every two (2) Plan Years (but not within eighteen (18) months of a prior audit). In the event Client requests to alter the scope of the claim audit, Company will endeavor to reasonably accommodate the Client’s request, which may be subject to additional charges to be mutually agreed upon by the Client and Company prior to the start of the audit. In no event shall any audit involve Plan benefit payments made prior to the most recent two (2) plan years.

Right to Audit Claims. Client may audit Company’s payment of Plan Benefits in accordance with the following requirements: A. Client shall provide to Company a scope of audit letter and the fully executed Claim Audit Agreement, a sample of which is attached hereto, together with a forty-five (45) day advance written request for audit. B. Client may designate with Company’s consent (which consent shall not to be unreasonably withheld) an independent, third-party auditor to conduct the audit (the “Auditor”). C. Client and Company will agree upon the date for the audit during regular business hours at Company’s office(s). D. Except as otherwise agreed to by the parties in writing prior to the commencement of the audit, the audit shall shal be conducted in accordance with the terms of Company’s Claim Audit Agreement attached hereto as “Claim Audit Agreement”, which is hereby agreed to by Client and which shall be signed by the Auditor prior to the start of the audit. E. If the audit identifies any claim adjustments, such adjustments will be made in accordance with this Agreement and based upon the actual claims reviewed and not upon statistical projections or extrapolations. F. Client shall be responsible for its Auditor’s costs. Client may (as determined by Company based upon the resources required by the audit requested) be responsible for Company’s reasonable costs with respect to the audit, except that while this Agreement is in effect there shall be no additional cost to Client for an audit of payment documents relating to a random, statistically valid sample of two-hundred twenty-five (225) claims paid during the two prior Plan years and not previously audited, provided that if Client has five thousand (5,000) or more employees who are Members, Client may conduct one such audit every Plan Year (but not within six (6) months of a prior audit); otherwise, Client ay may conduct one such audit every two (2) Plan Years (but not within eighteen (18) months of a prior audit). In the event Client requests to alter the scope of the claim audit, Company will endeavor to reasonably accommodate the Client’s request, which may be subject to additional charges to be mutually agreed upon by the Client and Company prior to the start of the audit. In no event shall any audit involve Plan benefit payments made prior to the most recent two (2) plan years.