Schedule N Definitions.docx

STATE OF MICHIGAN

RFP No. 200000001290

SCHEDULE N

DEFINITIONS

DEFINITIONS

24x7x365 means 24 hours a day, seven days a week, and 365 days a year (including the 366th day in a leap year).

Additional Service means any Services within the scope of the Contract, but not specifically provided under any Statement of Work.

Administration Fee means the agreed upon amount that will be paid to the Contractor by the Plan Sponsor for administration of the Plan.

A.M. Best Company means a credit rating organization serving the financial services industries, including the banking and insurance sectors.

A.M. Best Financial Strength Rating means an independent opinion, based on a comprehensive quantitative and qualitative evaluation, of a company's balance sheet strength, operating performance and business profile, as determined by A.M. Best Company.

Appeal means the formal procedures that address the review of adverse Organization Determinations on the dental services or products an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving services or products or on any amounts the enrollee must pay for a product or service after the services have been provided.

Approved Amount means the contractually defined price for Covered Products or Services specified by the Dental Plan and its contracted network providers.

Audit Period means the four year period following Contractor’s provision of any work under the Contract.

Benefit Guide means the publication that the Member receives which is developed and issued by the Contractor.

Bidder(s) are those companies that submit a proposal in response to this RFP.

Blanket Purchase Order is an alternate term for Contract and is used in the Plan Sponsor’s computer system.

Business Associate means a person assisting a Covered Entity in connection with its payment, treatment or health care operations, as more fully defined in 45 CFR §160.103.

Business Day (whether capitalized or not) must mean any day other than a Saturday, Sunday, or State-recognized legal holiday from 8:00 a.m. EST through 5:00 p.m. EST unless otherwise stated.

Claim means a submission for payment of a service.

Claimant means a Member who demands payment of Covered Services.

Claims Processing means the procedures that the Contractor uses to review a Claim for Member Eligibility, coverage determination, Provider payment, and Member obligation.

Coordination of Benefits (COB) means claims administration when Members are covered by more than one dental plan.

Contract Holder means a retiree, pension beneficiary, or COBRA participant who satisfies all of the eligibility criteria necessary to receive dental coverage through the Plan Sponsor.

Contractor means the organization selected to administer the Dental Plan for both Non-Medicare and Medicare Eligible members.

Copayment means a fixed dollar portion of the charge for Covered Services which must be paid by Members pursuant to the Plan Design.

Covered Entity means a health plan, a health care clearinghouse, or a health care Provider who transmits any health information in electronic form in connection with a HIPAA transaction. See Part II, 45 CFR 160.103.

Covered Product or Service means the dental examinations, cleanings, and procedures that are covered pursuant to the Plan Sponsor’s Plan Design.

Customer Assistance or Customer Service means a web based and/or telephonic system by which Members can make Inquiries about the Plan and the Contractor can answer or resolve them.

Data Management Vendor means a third party administrator of the Plan Sponsor’s database and reporting systems.

Days mean calendar days unless otherwise specified.

Dental Plan means a plan that provides coverage for dental services for the Plan Sponsor’s Members on behalf of the Plan Sponsor in accordance with this contract and RFP.

Deliverable means Covered Products or Services and reporting required or identified in a Statement of Work.

Dependent means an individual who satisfies, through a Contract Holder, all of the eligibility criteria necessary to receive dental coverages under the Plan Sponsor's Plan and is identified by the Plan Sponsor to the Contractor.

Direct Member Reimbursement (DMR) means a request for reimbursement of one or more Covered Products and/or Services submitted for payment by a Member.

Disruption Analysis means the identification of Members who are obtaining their dental care from Providers that are not participating in the new Contactor’s Provider Network and any proposed remediation to mitigate the disruption.

DTMB means the Michigan Department of Technology, Management and Budget.

Eligibility means the status of an individual with respect to their coverage under the Plan as determined by the Plan Sponsor.

Eligibility System means the database maintained by the Contractor that contains information on the effective dates of coverage for all Members that can be accessed by authorized individuals.

Eligible Claim means a submission for payment of a Covered Product or Service that is covered by the Plan, pursuant to the Plan Design.

Explanation of Benefits (EOB) means written statement sent to a Member, from the Contractor, after a claim has been reported, indicating the benefits and charges covered or not covered by the Plan.

Fee Schedule means the list of the approved amounts established or agreed to by Network Providers and the Contractor for specific Covered Products or Services.

Fully Insured means a plan where an entity contracts with another organization to assume financial responsibility for the group’s member claims and for all incurred administrative costs.

Grievance means any complaint or dispute, other than one involving an Organization Determination, expressing dissatisfaction with the manner in which a Dental Plan or delegated entity provides dental services, regardless of whether any remedial action can be taken. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item or service. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Dental Plan, provider, or facility.

Health Plan means a plan that provides health coverage for the Plan Sponsor’s Members.

HIPAA means the Health Insurance Portability and Accountability Act of 1996.

Implementation Period means the period of time between when Contractor is selected and Services are commenced on January 1, 2021.

Incident means any interruption in any function performed for the benefit of the Plan Sponsor.

Inquiry means any oral or written request to the Contractor, one of its Subcontractors, or received by Plan Sponsor and forwarded on to Contractor, that is not a Grievance does not involve a request for Appeal of any Organization Determination made by the Contractor.

Key Personnel means any Personnel identified in Section 3.3 as Key Personnel.

Member means each Contract Holder and eligible Dependent.

Member Materials mean those materials published by the Contractor for distribution to Members.

Membership Card means the card produced by the Contractor that documents the Member’s eligibility and coverage under the plan.

MPSERS means the Michigan Public School Employees’ Retirement System.

Network Provider means a Provider who has an agreement with the Contractor to provide Covered Products or Services to Members.

New Work means any Services/Deliverables outside the scope of the Contract and not specifically provided under any Statement of Work, such that once added will result in the need to provide the Contractor with additional consideration. “New Work” does not include Additional Service.

Organizational Determination means a decision by the Contractor to approve prior to service delivery a request for services or products and/or a determination by the Contractor to cover services or products after they have been obtained by a member.

ORS means Office of Retirement Services.

Pass-Through Pricing means that all charges to the Plan are equal to the Contractor’s payments to Providers without any additional charges that have not been explicitly disclosed to the Plan Sponsor.

Pharmacy Benefits Manager (PBM) means a third party administrator of prescription pharmaceutical programs that has been assigned a Business Identification Number (BIN) by The National Council for Prescription Drug Programs, Inc. (NCPDP).

Plan means the Plan Sponsor’s program which provides dental coverage to Members.

Plan Design means a description of the Plan Sponsor's Plan related to dental coverages and limitations thereto, including the framework of policies, interpretations, rules, practices and procedures applicable to such coverages, required and signed by the Plan Sponsor and submitted to Contractor.

Plan Sponsor means the Office of Retirement Services.

Plan Year means a calendar year, from January 1 through December 31.

Protected Health Information (PHI) means individually identifiable health information related to the past, present, or future physical or mental health or condition of a Member; the provision of health care to a Member; or the past, present or future payment for the provision of health care to a Member, as more fully defined in 45 CFR §164.501 or otherwise considered confidential under federal or state law.

Provider means a dental provider or facility that provides Covered Product or Services.

Provider Discount means the difference between what a Network Provider charges for Covered Services or Covered Products and the contractual amount that the Contractor is obligated to pay for those services or products

Provider Network means that set of Providers with which the Contractor has contracted to provide Covered Products or Services to Members. Contractor may have multiple Provider Networks. For pricing purposes, (1) in-network means the deepest discounted network and everything else is considered out of network, (2) the Plan Sponsor's liability for out of network providers is calculated based on cost share applied to their deepest discounted (a.k.a. in-network) network, (3) out of network providers that participate with Contractor via another fee schedule can charge members the difference between theirs and the in-network fee schedule but not balance bill up to their charge, and (4) non-participating providers can charge members the difference between the in-network fee schedule and their charge.

Reserved means that section is not applicable or included in this RFP. This is used as a placeholder to maintain consistent numbering.

Retiree means a member who retires with a retirement allowance payable from reserves of the retirement system. The Public School Employees Retirement Act. MCL 38.1307(4).

RFP means a Request for Proposal used to solicit proposals for services.

S & P means Standard and Poor’s credit rating agency.

Self-Insured means that the Plan Sponsor has financial responsibility for providing the funds used to pay Eligible Claims.

Services means any function performed for the Plan Sponsor as required in the Statement of Work.

SLA means Service Level Agreement or Performance Guarantee.

SSAE 16 means an auditing standard developed by the American Institute of Certified Public Accountants (AICPA).

Solicitation Materials means materials produced by the Contractor that describe the Plan to Members or eligible individuals.

Speed of Answer means the amount of time that elapses once a Covered Person call is placed into the Customer Service queue to the time the Covered Person call is answered by a Customer Service Representative (CSR) equates the Speed of Answer.

State Location means any physical location where the Plan Sponsor performs work. State Location may include state-owned, leased, or rented space.

Subcontractor means a company selected by the Contractor who is chosen to perform a portion of the Services, but does not include independent contractors engaged by Contractor solely in a staff augmentation role.

Third Party Administrator (TPA) means an entity who processes Claims pursuant to a service contract and who may also provide one or more other administrative services pursuant to a service contract, other than under a worker's compensation self-insurance program pursuant to section 611 of the Worker's Disability Compensation Act of 1969, 1969 PA 317, MCL 418.611. TPA does not include a carrier or employer sponsoring a plan.

Telephone Servicing Factor means the average time elapsed between when a caller elects to speak to a customer service representative and when the call is connected to a customer service representative.

Transparency means the full disclosure by the Contractor as to all of its sources of revenue that enables the Plan Sponsor (and its agents), as well as complete and full access to all information necessary to determine and verify that the Contractor has met all terms of this Contract and satisfied all Pass-Through Pricing requirements.

Unauthorized Removal means the removal of Key Personnel without the prior written consent of the Plan Sponsor.

Work Product means any data compilations, reports, and other media, materials, or other objects or works of authorship created or produced by the Contractor as a result of, and in furtherance of, performing the services required by this Contract.

Written Inquiries means any Inquiry, other than telephonic Inquiries, and includes letters, email, fax, or web portal.