Common use of Financial Incentives Clause in Contracts

Financial Incentives. Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Identification Card, by you or an unauthorized person, or if you fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx review firm and/or claim auditor. Alliant’s medical xxxx audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Financial Incentives. Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Your Identification Card, by you You or an unauthorized person, or if you You fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX BILL REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/complete/ legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx bill review firm and/or claim auditor. Alliant’s medical xxxx bill audit may be performed with or without records, and the review is not subject to waiver by any third-third- party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital hospital, or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Financial Incentives. Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstancesandcircumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Your Identification Card, by you You or an unauthorized person, or if you You fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX BILL REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvalsAuthorizationapprovals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx bill review firm and/or claim auditor. Alliant’s medical xxxx bill audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement third- partyagreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital hospital, or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and codingand billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Financial Incentives. ‌ Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs the appropriateness of care and circumstancesservices, and the local delivery systemexistence of coverage at the time the care was rendered. We do not specifically reward or compensate Physicians, Providers, Providers or other individuals for issuing denials of coverage. No financial Financial incentives are given to for staff to or agents do not encourage decisions that result in underutilization. PROOF OF LOSS, PAYMENT OF CLAIMS‌ In-Network Providers When services are provided by an In-Network Provider, claims will be filed by that Provider. You are not responsible for filing claims when services are rendered by an In-Network Provider. A Member shall make payment to a Physician or Provider rendering services under this Contract only to comply with those Copayments, Deductible, and out-of-pocket requirements outlined in the Summary of Benefits and Coverage. We are authorized by you to make payments directly to the Provider of Covered Services. Each person enrolled through the Plan receives an Identification Card. When admitted to an Alliant In-Network Hospital, present your Identification Card. Upon discharge, you may be billed only for those charges not covered by your Plan. The Hospital will xxxx us directly for Covered Services. Out-of-Network Providers When Covered Services are rendered out-of-network, services are performed by Out-of-Network Providers. Out-of-Network Providers are not required to file a claim on your behalf; you may have to pay the xxxx at the time of service and submit an itemized xxxx or claim to us for reimbursement. The claim should include your name, Member and Group ID numbers exactly as they appear on your Identification Card. Make certain the bills are itemized to include dates, places and nature of services and/or supplies. Be sure to keep a photocopy of all forms and bills for your records. BALANCE BILLING‌ In-Network Providers are prohibited from balance billing. In-Network Providers have signed an agreement with us to accept predetermined allowed amount for Covered Services rendered to a Member. A Member is not liable for fees in excess of the allowed amount, except what is due under the Contract, e.g., Copayments, Deductibles or Coinsurance. Out-of-Network Providers are not under an agreement with Alliant and may xxxx you for fees in excess of the MAC. FILING AND PAYMENT OF CLAIMS‌ You are responsible for giving your provider your correct health insurance policy information so claims can be filed properly. Always make certain you have your Identification Card with you. Be sure that Hospital or Physician’s office personnel copy your name, Group and Member numbers accurately when completing forms relating to your coverage. Based on the health coverage information you provide; your provider will submit claims to us for payment. If you are hospitalized at an Out-of-Network Hospital, the claim for Hospital services is usually handled in the same manner as with an In-Network Hospital and the Hospital files the claim. It may, however, be necessary for you to pay the Hospital or attending Physician for his or her services and then submit an itemized statement to us. If you need to submit a claim for services by an Out-of-Network Provider or reimbursement for services you had to pay, you must submit a claim form. You can obtain a blank claim form by visiting XxxxxxxXxxxx.xxx or calling Customer Service at (800) 811- 4793. • You have one-hundred and eighty (180) days from the date of service to submit a properly completed claim form with any necessary reports and records. • Payment of claims will be made as soon as possible following receipt of the claim, unless more time is required to obtain incomplete or missing information. In which case, we will notify you within fifteen (15) working days of receipt for electronic claims and thirty (30) calendar days of receipt for paper claims of the reason for the delay and list all information needed to continue processing your claim. • After this information is received by us, claims processing will be completed during the next fifteen (15) working days for electronic claims and thirty (30) calendar days for paper claims. • We shall pay interest at the rate of 12% per year to you or your assigned Provider if we do not meet these requirements. PHYSICAL EXAMINATIONS‌ If you have submitted a claim and we need more information about your health, we can require you to have a physical examination. We would pay the cost of any such examination. NONDISCRIMINATION‌ TTY/TDD‌ If you speak another language, language assistance services are available, free of charge. For TTY/TDD access call (800) 000- 0000. QUESTIONS ABOUT COVERAGE OR CLAIMS‌ If you have questions about your coverage or claims, contact your Plan Administrator or Alliant Customer Service at (000) 000-0000. Be sure to always give your Member ID number. When asking about a claim, provide the following information: • Member ID number; • Patient name and address; • Date of service; • Type of service received; and • Provider name and address (Hospital or doctor). TERMS OF YOUR COVERAGE‌ We provide the benefits described in this booklet only for eligible Members. The health care services are subject to the limitations, exclusions, Copayments, Deductibles and Coinsurance requirements specified in your Summary of Benefits and Coverage. This Certificate of Coverage supersedes any previously distributed Certificate of Coverage. Benefit payment for Covered Services or supplies will be made directly to whoever submits the claim. If the Provider submits the claim, we will make payment to the Provider. If you submit the claim, payment will be made directly to you and you are responsible for making payment to the Provider. We do not supply you with a Hospital or Physician. In addition, we are not responsible for any Injuries or damages you may suffer due to actions of any Hospital, Physician or other person. In order to process your claims, we may request additional information about the medical treatment you received and/or other health insurance you may have. This information will be treated confidentially. An oral explanation of your benefits by an Alliant employee is not legally binding. Any correspondence mailed to you will be sent to your most current address. You are responsible for notifying us of your new address. FRAUD OR MISREPRESENTATION MISREPRESENTATION‌ Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Identification Card, by you or an unauthorized person, or if you fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX REVIEW ACTS BEYOND REASONABLE CONTROL (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves FORCE MAJEURE)‌ Should the right to request and review medical records in order to allow performance of any act required by this coverage be prevented or delayed by reason of any act of God, strike, lock- out, labor troubles, restrictive government laws or regulations, or any other cause beyond a party’s control, the time for the determination performance of benefits according the act will be extended for a period equivalent to the Contractperiod of delay, and non-performance of the act during the period of delay will be excused. In accordance such an event, however, all parties shall use reasonable efforts to perform their respective obligations. CARE RECEIVED OUTSIDE THE U.S.‌ Non-emergency care is not a covered service outside the United States. You will receive Contract benefits for only emergency care and/or treatment received outside the United States. Contract provisions will apply. Any care received must be a Covered Service. Please pay the provider of service at the time you receive treatment and obtain appropriate documentation of services received including bills, receipts, letters and medical narrative. This information should be submitted with your claim. All services will be subject to appropriateness of care. We will reimburse you directly. Payment will be based on the MAC. You may not assign benefits to foreign Providers or facilities. MEDICARE‌ Any benefits covered under both this Certificate and Medicare will be paid pursuant to Medicare Secondary Payer legislation, regulations, and Centers for Medicare and Medicaid Services guidelines. Federal law controls whenever there is a conflict among state law, Certificate provisions and federal law. Except when federal law requires Alliant to be the primary payer, the benefits under this Certificate for Members age 65 and older, or Members otherwise eligible for Medicare, do not duplicate any benefit for which Members are entitled under Medicare, including Parts B and/or D. Where Medicare is the responsible payer, all sums payable by Medicare for services provided to Members shall be reimbursed by or on behalf of the Members, to the extent Alliant has made payment for such services. For Medicare Parts B and D, Alliant will calculate benefits upon receipt of the Member’s Explanation of Medicare Benefits (EOMB) or for Part D payment data obtained from an authorized Prescription Benefit Manager (PBM). WHEN YOUR COVERAGE TERMINATES‌ When will my Alliant Membership end?‌ Alliant Health Plans will renew or continue your coverage if you wish to remain enrolled. The Affordable Care Act preserves existing requirements under HIPAA that require insurers to renew coverage on a guaranteed basis with some exceptions, such as the nonpayment of premiums and fraud, among others, that are explained below. TERMINATION OF BENEFITS & COVERAGE‌ The termination date of your coverage is the first day you are not covered with Alliant (for example, if your termination date is July 1, 2014, your last minute of coverage was at 11:59 p.m. on June 30, 2014). If your coverage terminates for any reason, you must pay all amounts payable and owed related to your coverage with Alliant’s policies and procedures, including Premiums, for the period prior to your termination date. Except in the case of fraud or deception in the use of services or facilities, Alliant will return to you within 30 days the amount of Premiums paid to Alliant which corresponds to any unexpired period for which payment had been received together with amounts due on claims, if any, less any amounts due Alliant. Your membership with Alliant will terminate if you: • No Longer Meet Eligibility Requirements: o You no benefits will be payable by Alliant if longer meet the health care provider does not submit a Clean Claim, obtain age or other eligibility requirements for coverage under this plan as required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx review firm and/or claim auditorthe Marketplace. o You no longer live in Alliant’s medical xxxx audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines Service Area for this product. The Marketplace and/or Alliant will send you notice of any health care provider (e.g., physician, hospital or other facility)eligibility determination. Alliant will evaluate Clean Claims to ensure that send you notice when it learns you have moved out of the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical recordsService Area. All Contract/claim adjudication determinations Coverage will be made using Alliant’s Policies and Procedures that are based end at 11:59 p.m. on the coding and billing guidelines last day of the American Medical Associationmonth following the month in which either of these notices is sent to you unless you request an earlier termination effective date. o For Dependents, upon reaching age 26, your coverage will terminate at the CMS’/Federal Government’s guidelines for proper coding end of the calendar year in which you turn 26. • Request Disenrollment: You decide to end Your membership and billingdisenroll from Alliant by notifying Alliant if you purchased directly from us or the Marketplace if you purchased from the Health Insurance Marketplace. Your membership will end at 11:59 p.m. on the 14th day following the date of your request or a later date if requested by you. Alliant may, includingat its discretion, accommodate a request to end your membership in fewer than 14 days, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:accommodate any requests to end membership earlier than the date of your request.

Financial Incentives. Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Your Identification Card, by you You or an unauthorized person, or if you You fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx review firm and/or claim auditor. Alliant’s medical xxxx audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Financial Incentives. Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Identification Card, by you or an unauthorized person, or if you fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. MEDICAL XXXX BILL REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx bill review firm and/or claim auditor. Alliant’s medical xxxx bill audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Financial Incentives. ‌ Medical Management decision making is based only on Medical Necessity criteria, a member’s benefit plan, individual needs and circumstances, and the local delivery system. We do not reward or compensate Physicians, Providers, or other individuals for issuing denials of coverage. No financial incentives are given to staff to encourage decisions that result in underutilization. FRAUD OR MISREPRESENTATION Fraudulent statements and/or intentional misrepresentation on application forms, claims, Identification Cards or other identification to obtain services or a higher level of benefits are prohibited. This includes, but is not limited to, the fabrication and/or alteration of a claim, Identification Card or other identification. Misrepresentation involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for rescinding coverage. This includes fraudulent acts to obtain medical services and/or Prescription Drugs. Unauthorized use of your Identification Card, by you or an unauthorized person, or if you fraudulently use the Identification Card of another covered person, including but not limited to the use of card before coverage is in effect or after coverage has ended. Under these circumstances, the person who receives the services provided by misuse of the Identification Card will be responsible for payment of those services. Fraudulent misuse could also result in termination of the coverage. GOVERNMENTAL HEALTH CARE PROGRAMS If you are enrolled in a group with fewer than twenty (20) employees, your benefits will be reduced if you are enrolled for coverage under any federal, state (except Medicaid) or local government health care program. Under federal law, for groups with twenty (20) or more employees, all active employees (regardless of age) can remain on the group’s health plan and receive group benefits as primary coverage. Also, spouses (regardless of age) of active employees can remain on the group’s health plan and receive group benefits as primary coverage. MEDICAL XXXX BILL REVIEW (MBR) AND CLAIM AUDIT PROVISION All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent xxxx bill review firm and/or claim auditor. Alliant’s medical xxxx bill audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that: