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HomeMy Public PortalAboutExhibit MSD 69 - Cigna Medial & DentalExhibit MSD 69 CIGNA Implementation Guide List of Documents Requiring Signature There are a number of documents that are critical to the case implementation process. Enclosed: Group Application Delegation of Discretionary Claim Authority Form Binder Check* HIPAA Declaration NYHCRA Attachment DOH - 4403 Provided by Sales: Stop Loss Application Performance Guarantee Agreement ASO Agreement/Letter of Intent Producer Acknowledgement Form Customer Acknowledgement Form Provided by Banking: Banking Documents *CIGNA HealthCare requires a Binder Check as a deposit on all new business. The binder check will be applied to your first month's bill. Without the proper documents and signatures, the case implementation process cannot be completed. Timely receipt of these documents is essential to a successful implementation. NEW YORK STATE DEPARTMENT OF HEALTH Division of Health Care Financing Third Party Aumiinistrator (TPA) or Administrative Services Only (ASO) Status Change HEALTH CARE REFORM ACT - PUBLIC GOODS POOL INSTRUCTIONS This form is to be completed by a payor whose status has changed from the original election as it relates to whether a TPA/ASO is utilized for claims processing. Effective Date: Enter effective date of status change. Payor Information: Enter payor name, federal identification number (FEIN), contact person, and phone #. Type of Status Change: If you are adding or changing a TPA/ASO organization, check appropriate box on type of status change being submitted. Previous TPA/ASO Information: Enter previous TPA/ASO name/FEIN, if applicable. New or Additional TPA/ASO Information: Enter new or additional TPA/ASO name, FEIN, address, contact person, and phone number. Check one of the following: Check appropriate box regarding claims run out, if applicable. Signature Section: An authorized individual from the electing payor's company must sign and date the form. DOH -4403 (9/2006) NEW YORK STATE DEPARTMENT OF HEALTH Division of Health Care Financing Third Party A,...,inistrator (TPA) or Administrative Services Only (ASO) Status Change HEALTH CARE REFORM ACT — PUBLIC GOODS POOL This form must be completed if an electing payor is adding or changing their TPA/ASO. Effective Date: 02/01/2012 PAYOR INFORMATION: Payor Name: The Metropolitan St. Louis Sewer District Payor FEIN: 43-6011991 Contact Person: Lorraine Jackson Phone #: 314-768-2715 Type of Status Change (check appropriate box): 0 Additional TPA/ASO (complete Section II only) © Changing TPA/ASO (complete Sections I, II & III) L PREVIOUS TPA/ASO INFORMATION: TPA/ASO Name: United Healthcare TPA/ASO FEIN: 43-1361841 II. NEW or ADDITIONAL TPA/ASO INFORMATION: TPA/ASO Name: Connecticut General Life Insurance Company TPA/ASO FEIN: 06-0303370 Address: 53 Glenmaura National Boulevard Moosic, PA 18507 TPA/ASO Contact Person: Lea Anna Tonkin TPA/ASO Phone #: 570-496-5381 III. CHECK ONE OF THE FOLLOWING: 0 Previous TPA/ASO will continue to process claims and file reports for all dates of service prior to the change for a period of one year following the end of the year in which the change in TPA occurred or until all such claims have been adjudicated, at which time a final monthly report with a copy of this form indicating same will be filed. ❑ AlI self -insured claims that previous TPA/ASO was responsible for have been adjudicated effective 0 New TPA/ASO is suming responsibility for all pending claims and HCRA reporting requirements. j Signature of Payor: Date: ra Please mail completed form to: Mr. Jerome Alaimo, Pool Administrator Office of Pool Administration Excellus BlueCross BlueShield, Central New York Region P.O. Box 4757 Syracuse, New York 13221-4757 DOH -4403 (9/2006) Page 1 of 1 Cigna HealthCare HIPAA Certification Declaration Agreement The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that a proof of prior coverage certificate (HIPAA Certificate) be issued to individuals who, for any reason, have lost their active or COBRA medical plan coverage. For fully insured customers, Cigna HealthCare will automatically generate individual HIPAA Certificates for members and their dependents unless the employer has declined this service by indicating below (unless required by state law). For self -insured customers, Cigna HealthCare will not provide this service unless the customer elects this optional service by indicating below. Please complete the following information and return this Declaration Agreement to: Cigna HealthCare 900 Cottage Grove Rd, C1MIG Bloomfield, CT 06152 Or fax: 860.226.3575 1. Account Name: The Metropolitan St. Louis Sewer District 2. Contact Name: Title: Phone: 3. Contact Address: 2350 Market Street City: St. Louis State: MO Zip: 63103 - 4. Account Number(s): 3335464 Please select one of the following: ❑ We do not elect to use Cigna HealthCare Certification Services. We will have full responsibility to comply with the issuance of HIPAA Certificates as required by federal law. ❑ We elect to have Cigna HealthCare perform HIPAA Certification Services. We acknowledge that Cigna HealthCare's ability to provide HIPAA Certificates may be dependent on the quality of information provided by us. We understand that CIGNA HealthCare is responsible only for coverage periods administered by Cigna HealthCare. If you have elected Cigna HealthCare to perform the services, please complete the following: 5. START DATE: For new accounts, the start date will be the account effective date. For existing accounts, please indicate one of the following: ❑ At renewal / / OR ® As of 02 / 01 / 2012 . 6. Type of Medical Coverage (Check all that apply): ❑ Commercial HMO/POS ® Indemnity/PPO/OAP ❑ Point-of-Service/FlexCarelNetwork ❑ Preferred Provider Access 7. Type of Funding Arrangement (check one box): ❑ Insured ® ASO/Self-Funded ❑ Both 8. If you have elected the HIPAA certification services, Cigna HealthCare will generate quarterly reports of HIPAA Certificates that were generated for your account. Please indicate if you would like to receive this report: ❑ Yes ❑ No Sig at e Date Note: If you have elected to have Cigna HealthCare perform the HIPAA certification service, you will receive a report upon termination of your account. In accordance with HIPAA, no individual HIPAA Certificates will be issued. This report may be used to provide prior coverage information to a new administrator or carrier. APPROVED AS TO FORM v..-.....- nemh /Ao Date DELEGATION OF DISCRETIONARY CLAIM AUTHORITY PLEASE RETURN THIS SIGNED FORM TO YOUR SALES REPRESENTATIVE Plan Administrator: The Metropolitan St. Louis Sewer District Claim Administrator: CIGNA Healthcare / Connecticut General Life Insurance Company Policy Number: 3335464 Policyholder: The Metropolitan St. Louis Sewer District The Plan Administrator named above hereby delegates to the Claim Administrator the discretionary authority to interpret and apply plan terms and to make factual determinations in connection with its review of claims under the plan. Such discretionary authority is intended to include, but is not limited to, the determination of the eligibility of persons desiring to enroll in or claim benefits under the plan, the determination of whether a person is entitled to benefits under the plan, and the computation of any and' all benefit payments. The Plan Administrator also delegates to the Claim Administrator the discretionary authority to perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by the claimant or his duly authorized representative. a Sign CI i k4r€i1 ri Name rLXtetc vt Alit (-Iry Position/Title 12-115 hi If you sign this form, this language will be made a part of your Summary Plan Description. APPROVED AS TO FORM of By: It i .i if /IL . Application for Group Insurani 1. Name of Applicant The Metropolitan St. Louis Sewer District 3. Nature of Business 4. Classes and Locations of Individuals Eligible Ali Eligible Employees and Retirees Insured and/or Administered Ir Connecticut General Life Insure Company CIGNA HealthCare Hartford, CT 06152 2. Main Address 2350 Market Street, St Louis, MO 63103 4952 - Sewerage Systems 5. Subsidiary and Affiliated Companies Included For Dependent Benefits 1,033 CIGNA 6. Total Number of Individuals Eligible For Individual Benefits 1,033 1,033 Have any of the classes of individuals eligible been covered under a group insurance policy or any other form of group plan within the past five years? Yes ElNo if so, please specify the benefits, the underwriting company or organization, and the dates these benefits were terminated. Medical Coverage: United Healthcare / Dental Coverage: Ameritas Life ins. Corp - Coverages terminating 01/31/2012 ii 7. Group Insurance Applied For. (Please check all that apply) Individual Dependent El 111 Life Insurance Accidental Death & Dismemberment Insurance Short Term Disability insurance Long Term Disability Insurance Hospital Benefits Surgical Benefits individual El Dependent ❑ Doctors Attendance Benefits ❑ Laboratory and X-ray Examination Benefits ❑ , . . Major Medical Benefits • Comprehensive Medical Benefits El. Dental Benefits ❑ Vision Care Benefits 8. Effective Date Requested: 02/01/2012 Group Insurance at the Insurance Company's rates and under the terms of the policy(s) applied for will take effect on the Effective Date Requested if the Application is accepted at the Home Office of the Insurance Company. If certain persons eligible are to contribute to the cost of the Group Insurance, such Group Insurance will take effect on the later of: the date the required number have enrolled, or on the Effective Date Requested. If this Application is not accepted, no insurance will become effective. Any premium advanced by the Applicant will be refunded upon surrender of this Conditional Receipt. 9. THE APPLICANT DECLARES: that he has read the above statement and the answers to the above questions are complete and true. The Applicant agrees: (1) that this Application is offered as an inducement for the Group Insurance applied for, (2) that the terms and conditions of the Insurance Company's Proposal for the Group Insurance applied for forms a part of this Application and that this Application will form a part of any policy(s) issued; and (3) that no agent will have the authority to waive a complete answer to any question in the application, pass on insurability, make or alter any contract, or waive any of the company's other rights or requirements unless signed by an Executive Officer of the Insurance Company. Group Insurance MI only be provided for persons eligible under the policy(s) issued. Dated at Nam pliant The Metropolitan St. Louis Sewer District By Title Witness Soliciting Agent if other than Witness on PRESENTSANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR R BENEFIT R ONGLY FALSE INFORMATION IN AN APPLICATION FOR SURANCE IS GUILTY OF PAYMENT RIME AND MAY O BE SUBJECT OEFINES AND CONFINEMENT IN PRISON. STATEMENT TO BE SIGNED BY APPLICANT UPON PAYMENT OF THE PREMIUM OR ANY PART THEREOF I HEREBY DECLARE that I have paid to Agent $85,000.00 Dollars for which I hold his receipt. Date Applicant Agent Agent's License No. GMSOOS V2 Cat #280448 (MO) Rev. 11-08 Conditional Receipt Arm VED AS TO FORM iiii1 i $85,000.00 Dollars Received of The Metr pout. � �, . L ;�; , . , i!le;y %f .'� 10 be applied against the first premium on 1r- proposed Group Insure +- this Application, This payment is made and accepted subject to the following conditions. Group InsA_ .e.at the Inor..........-0.,.,.,.;.,.,b ,ulw Il,,.h.,,dtn the terms of the policy(s) applied for will take effect as of the Effective Date Requested if the Application is accepted at the Home Office of the Insurance Company. If certain persons eligible are to contribute lo the cost of the Group Insurance, such Group Insurance will take effect on the later oi: the date the required number have enrolled, or on the Effective Date Requested. 11 the Application is not accepted, no insurance will become effective. Any premium payment advanced by the Applicant will be refunded upon surrender of this Conditional Receipt. Insured and/or Administered by Connecticut General Life Insurance Company CIGNA HealthCare Hartford, CT 06152 f'.r. Date Agent A ent's License No. DETACH THIS RECEIPT WHEN PAYMENT IS MADE CIGNA Cat #280448 (MO) Rev. 11.08 GM58O4 V2 Invoice Number 3335464 01/10/2 Date 01-10-12 THE METROPOLITAN ST. LOUIS SEWER DISTRICT 2350 MARKET STREET ST. LOUIS. MISSOURI 63103-2555 Invoice Massage BINDER CHECK Invoice Amount 85,000.00 NUMBER 625285 Discount Total WA NINGfTIIS'CHECRHAS filETHIDt N VDID.FEATtJRE # `i bPOUtla' Louistr*# S :.00I&:IISSI ga1PS-555 . EV8te 0.00 Amount Paid 85,000.00 85,000.00 :PAY"EXACTLY $***85,000 DOLLARS AND 00 CENTS $***85,00.0'.00 VOID if not cashed within 90 days CIGNA'.HEALTHCARE P 0 :.BOX 644546 PIT.TSBURGHPA .1.5264-4546 II' 252851I' an ai signatures required tor amou over $4. 9.99) ':08 10000 3 21: DO 3484 3475480 ORDINANCE NO. 14015 AN ORDINANCE, authorizing the Executive Director and Secretary -Treasurer on behalf of The Metropolitan St. Louis Sewer District to enter into a contract with CIGNA for medical plan benefits for the District's employees and family members. NOW, THEREFORE, BE IT ORDAINED BY THE BOARD OF TRUSTEES OF THE METROPOLITAN ST. LOUIS SEWER DISTRICT: Section One. The Executive Director and Secretary -Treasurer are hereby authorized on behalf of The Metropolitan St. Louis Sewer District to enter into a contract with CIGNA for medical plan benefits for the District's employees and family members for the period February 1, 2015 to January 31, 2016. Section Two. The contract authorized in Section One of this ordinance shall provide that employee eligibility shall be determined by the District; that the contract may be renewed from year-to-year at the option of the District, unless otherwise terminated; and for such other terms and conditions as are approved by the office of the General Counsel of the District. The foregoing Ordinance was adopted on December 11, 2014. ORDINANCE NO. 14016 AN ORDINANCE, authorizing the Executive Director and Secretary -Treasurer on behalf of The Metropolitan St. Louis Sewer District to enter into a contract with CIGNA for dental plan benefits for the District's employees and family members. NOW, THEREFORE, BE TT ORDAINED BY THE BOARD OF TRUSTEES OF THE METROPOLITAN ST. LOUIS SEWER DISTRICT: Section One. The Executive Director and Secretary -Treasurer are hereby authorized on behalf of The Metropolitan St. Louis Sewer District to enter into a contract with CIGNA for dental plan benefits for the District's employees and family members for the period February 1, 2015 to January 31, 2016. Section Two. The contract authorized in Section One of this ordinance shall provide that employee eligibility shall be determined by the District; that the contract may be renewed from year-to-year at the option of the District, unless otherwise terminated; and for such other terms and conditions as are approved by the office of the General Counsel of the District. The foregoing Ordinance was adopted on December 11, 2014.