Eligibility Files Clause Samples
The 'Eligibility Files' clause defines the requirements and procedures for providing and maintaining records that verify which individuals are eligible for certain benefits or services under an agreement. Typically, this clause outlines the format, frequency, and method by which eligibility information—such as lists of covered employees or dependents—must be submitted to the relevant party, often an insurer or plan administrator. By establishing clear guidelines for the exchange and updating of eligibility data, the clause helps prevent disputes over coverage, ensures accurate administration of benefits, and reduces the risk of errors or omissions in service delivery.
Eligibility Files. Client will provide to Marathon on a weekly basis, or other mutually agreed-upon frequency, a Participant eligibility file, which is necessary to enable Marathon to provide the Marathon Services. The Participant eligibility file will contain the entire population of Participants and will adhere to Marathon’s file specifications.
Eligibility Files. Client agrees to upload on MTM’s secure SFTP server, API or client portal on the first business day of each month, or agreed upon schedule a listing all active members for which MTM may provide telemedicine services under this Agreement.
Eligibility Files. Electronic transmissions: If the Eligibility File is not readable, the receiving party agrees to notify the sender within seven (7) business days from receipt of the file by telephone. The sender shall send a replacement Eligibility File to the receiving party. Until receipt of the replacement Eligibility File, the CMS Contractor will transfer claims based on the last transmitted Eligibility File that was readable and was posted to CMS’ Common Working File. If the sender does not receive a COBA Eligibility File Acknowledgement (EFA) and Eligibility Response File (ERF) within the timeframes described in the COBA Implementation Guide, the sender shall contact the CMS Contractor by telephone as listed in Section II.B of the Attachment.
Eligibility Files. Contractor shall:
Eligibility Files. The TPA will be required to maintain HIPAA compliant information on each participant. In addition to such information, the Board requires that the following information be captured and maintained in the TPA's eligibility system:
1. Participant’s name, date of birth, home address, phone number and email address;
2. Participant’s unique identification number;
3. Participant’s and any covered dependents’ Social Security numbers;
4. Dependent child(ren)’s address (if different than parent);
5. Effective dates of coverage, changes and terminations for participants and dependents;
6. Subgroups The Plan currently has eight (8) subgroups which include active employees, COBRA participants, Medicare eligible service or disabled retirees over 65, Medicare eligible disabled retirees under 65, disabled retirees without Medicare, service retirees without Medicare, active employees with life insurance only coverage and retirees with life insurance only coverage;
7. Participant’s marital status;
8. Participant’s Employer Unit identifier;
9. Participant’s payroll location;
10. Life insurance amount;
11. Qualifying event timeframe (i.e. 18 months, 36 months) for COBRA participants;
12. Family Cross-Reference The Plan requires that active employees be covered under their own individual contract and prohibits active employees from being covered as a dependent under another Plan contract. Also, a dependent child can be covered under only one (1) Plan contract. Family cross-reference is also required for the accumulation of the family deductible;
13. Disabled Dependents - The TPA is responsible for verifying, through medical review, that the dependent qualifies for continued coverage as a disabled dependent;
14. Eligibility History Historical information to be maintained includes, but is not limited to, prior contract types (e.g. single, family), prior coverage dates for dependents prior subgroups, etc.; and
15. Online Membership/Eligibility The TPA must provide OI staff read-only access to membership/eligibility and claims information via an online system.
Eligibility Files. (a) CLIENT shall provide BENECARD PBF with a true, accurate and complete eligibility file, in an electronic or paper format, on a frequency mutually agreeable to CLIENT and BENECARD PBF, identifying all eligible Members and their dependents, together with all relevant information required by BENECARD PBF to process Claims and to provide its services under this Agreement. The full file format shall include CLIENT number, group code, Member I.D., effective date, last name, first name, gender, relation code, birth date, primary ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇, ▇▇▇▇▇, and five (5) digit zip code for each member and dependent. Partial or change file formats must be agreed to between the parties. CLIENT shall be solely responsible for ensuring the accuracy of its eligibility records as submitted to BENECARD PBF, and shall be obligated to pay BENECARD PBF for all amounts due to BENECARD PBF hereunder for Claims for Members shown as eligible on the date the claim was adjudicated.
(b) Eligibility updates shall be prospective and shall be provided before the Member effective date for new adds, and shall include, but not be limited to, changes in enrollment status, such as additions of Members and dependents, name changes, address changes, contact information updates, group effectivedates and termination dates of members and/or dependents resulting from divorce, marriage, death, etc., coverage reinstatements, survivor benefit updates, together with the effective date of all such changes. Eligibility updates shall be provided by CLIENT in a format and on a frequency mutually agreeable to CLIENT and BENECARD PBF. BENECARD PBF will implement CLIENT’s changes to the eligibility updates provided CLIENT notifies BENECARD PBF of such changes in accordance with the provisions of this Agreement. Terminated Members may be reported retrospectively. In the event a terminated Member uses his/her Prescription Drug benefits prior to receipt of the update, the claim charges incurred on behalf of such individual, and the associated administrative fee, will be the responsibility of CLIENT.
Eligibility Files. By the 1st day of each month, Employer, or its third party administrator, shall deliver to Teladoc Health an accurate file identifying the number of Employees eligible to utilize the HealthiestYou Virtual Care Services in that month (the “Eligibility File”) and their applicable contact information (including name, street address, and email address), in a format approved by Teladoc Health. If Employer, or its third party administrator, fails to deliver the Eligibility File by the 1st day of the month, then the last valid Eligibility File delivered to Teladoc Health will be deemed to be the Eligibility File for that month. Alternatively and as applicable, Employer may either provide Eligibility File information via Teladoc Health’s Client Site portal, or via a Real Time Eligibility (RTE) process, as mutually agreed by the Parties. If Employer subsequently requests a modification to their method of delivering Eligibility File information, Teladoc Health may charge the Employer an additional fee of two hundred dollars ($200) per hour, times that number of hours necessary to effect such modification.
Eligibility Files. Client will provide to MRS on a monthly basis a Participant eligibility file, which is necessary to enable MRS to provide the services outlined and agreed-upon in this Agreement. The Participant eligibility file will contain the updated and entire population of Participants and comply with MRS’s file specifications.
Eligibility Files. Client shall provide Concentra the initial eligibility file at least thirty (30) days prior to the anticipated open for business date. Client shall provide ongoing weekly updates, which shall include the participant eligibility file necessary to enable Concentra to provide Onsite Center Services and reporting. The participant eligibility file will contain the entire eligible population with the targeted population delineated within the file. Prior to execution of this Agreement, Concentra will provide eligibility file standards to Client upon request. After execution of this Agreement, Client will cooperate with Concentra to identify specific data required to fulfill this Agreement. Concentra shall communicate the file specifications to Client, including the automated process for ongoing file transmission. Client acknowledges that Concentra cannot provide services and reporting without eligibility files from Client meeting the specifications as provided by Concentra.
Eligibility Files. No later than 30 days prior to the Start Date, Client shall deliver to Best Doctors a report that lists all employees expected to be eligible to utilize the Services (“Client Employees”) as of the Start Date (the “Client Eligibility File”). Thereafter, Client shall, at a minimum, deliver monthly an updated Client Eligibility File to Best Doctors no later than the first day of each month that lists (a) all Client Employees for that month; provided, however, that if Client fails to deliver such a report before the first day of any month during the Term, then the last Client Eligibility File delivered to Best Doctors will be deemed to be the Client Eligibility File for that month. Any corrections to a Client Eligibility File must be delivered by Client to Best Doctors within 6 months following the date of submission of such file.