CLAIM FILING AND PROVIDER PAYMENTS This section provides information regarding how a member may file a claim for a covered healthcare service and how we pay providers for a covered healthcare service. Network providers file claims on your behalf. Non-network providers may or may not file claims on your behalf. If a non-network provider does not file a claim on your behalf, you will need to file it yourself. To file a claim, please send us the provider’s itemized bill, and include the following information: • your name; • your member ID number; • the name, address, and telephone number of the provider who performed the service; • date and description of the service; and • charge for that service. Please send your claim to the address listed in the Contact Information section. Claims must be filed within one calendar year of the date you receive a covered healthcare service. Claims submitted after this deadline are not eligible for reimbursement. This timeframe does not apply if you are legally incapacitated. We pay network providers directly for covered healthcare services. Network providers agree not to bill, charge, collect a deposit from, or seek reimbursement from you for a covered healthcare service, except for your share under the plan. When you see a network provider, you are responsible for a share of the cost of covered healthcare services. Your share includes the deductible, if one applies, and the copayment, as listed in the Summary of Medical Benefits. The covered healthcare service may also have a benefit limit, which caps the amount we will reimburse the provider for that service. You will be responsible for any amount over the benefit limit, up to the allowance. Your provider may request these payments at the time of service, or may bill you after the service. If you do not pay your provider, the provider may decline to provide current or future services or may pursue payment from you, such as beginning collection proceedings. Some of our agreements with network providers include alternative payment methods such as incentives, risk-sharing, care coordination, value-based, capitation or similar payment methods. Your copayments are determined based on our allowance at the date the service is rendered. Your copayment may be more or less than the amount the network provider receives under these alternative payment methods. Your copayment will not be adjusted based on these alternative payment methods, or for any payment that is not calculated on an individual claim basis. Our contracts with providers may establish a payment allowance for multiple covered healthcare services, and we may apply a single copayment based on these arrangements. In these cases, you will typically be responsible for fewer copayments than if your share of the cost had been determined on a per service basis.
Document Retention and Record Maintenance The HSP will
(a) retain all records (as that term is defined in FIPPA) related to the HSP’s performance of its obligations under this Agreement for 7 years after the termination or expiration of the term of this Agreement;
(b) keep all financial records, invoices and other finance-related documents relating to the Funding or otherwise to the Services in a manner consistent with either generally accepted accounting principles or international financial reporting standards as advised by the HSP’s auditor; and
(c) keep all non-financial documents and records relating to the Funding or otherwise to the Services in a manner consistent with all Applicable Law.
Production of Witnesses; Records; Cooperation (a) After the Effective Time, each Party shall use its commercially reasonable efforts to make available to the other Party, upon written request, the former, current and future directors, officers, employees, other personnel and agents of the members of its respective Group as witnesses and any books, records or other documents within its control or which it otherwise has the ability to make available without undue burden, to the extent that any such Person (giving consideration to business demands of such directors, officers, employees, other personnel and agents) or books, records or other documents may reasonably be required in connection with any Action in which the requesting Party (or member of its Group) may from time to time be involved, regardless of whether such Action is a matter with respect to which indemnification may be sought hereunder. The requesting Party shall bear all costs and expenses in connection therewith.
(b) If an Indemnifying Party chooses to defend or to seek to compromise or settle any Third-Party Claim, the other Party shall make available to such Indemnifying Party, upon written request, the former, current and future directors, officers, employees, other personnel and agents of the members of its respective Group as witnesses and any books, records or other documents within its control or which it otherwise has the ability to make available without undue burden, to the extent that any such Person (giving consideration to business demands of such directors, officers, employees, other personnel and agents) or books, records or other documents may reasonably be required in connection with such defense, settlement or compromise, or such prosecution, evaluation or pursuit, as the case may be, and shall otherwise cooperate in such defense, settlement or compromise, or such prosecution, evaluation or pursuit, as the case may be.
(c) Without limiting the foregoing, the Parties shall cooperate and consult to the extent reasonably necessary with respect to any Actions.
(d) Without limiting any provision of this Section 6.7, each of the Parties agrees to cooperate, and to cause each member of its respective Group to cooperate, with each other in the defense of any infringement or similar claim with respect any Intellectual Property and shall not claim to acknowledge, or permit any member of its respective Group to claim to acknowledge, the validity or infringing use of any Intellectual Property of a third Person in a manner that would hamper or undermine the defense of such infringement or similar claim.
(e) The obligation of the Parties to provide witnesses pursuant to this Section 6.7 is intended to be interpreted in a manner so as to facilitate cooperation and shall include the obligation to provide as witnesses inventors and other officers without regard to whether the witness or the employer of the witness could assert a possible business conflict (subject to the exception set forth in the first sentence of Section 6.7(a)).
Cooperation and Records Retention Seller and Buyer shall (i) each provide the other with such assistance as may reasonably be requested by any of them in connection with the preparation of any return, audit, or other examination by any taxing authority or judicial or administrative proceedings relating to liability for Taxes, (ii) each retain and provide the other with any records or other information that may be relevant to such return, audit or examination, proceeding or determination, and (iii) each provide the other with any final determination of any such audit or examination, proceeding, or determination that affects any amount required to be shown on any tax return of the other for any period. Without limiting the generality of the foregoing, Buyer and Seller shall each retain, until the applicable statutes of limitations (including any extensions) have expired, copies of all tax returns, supporting work schedules, and other records or information, in a timely manner, as and that may be relevant to such returns for all tax periods or portions thereof ending on or before the Closing Date and shall not destroy or otherwise dispose of any such records without first providing the other party with a reasonable opportunity to review and copy the same.
File Management and Record Retention relating to CRF Eligible Persons or Households Grantee must maintain a separate file for every applicant, Eligible Person, or Household, regardless of whether the request was approved or denied.
a. Contents of File: Each file must contain sufficient and legible documentation. Documents must be secured within the file and must be organized systematically.