Health Net 2009 Annual Report Download - page 531

ARTICLE VI.
CLAIMS HANDLING
Section 6.1. Claim Administration Services. From and after the Effective Date, the Administrator shall acknowledge, consider,
review, deny, settle, pay or otherwise dispose of each Claim reported under each Administered Contract. Notwithstanding the
preceding sentence, the Company retains the final binding and exclusive discretionary authority with regard to the administration and
disposition of all Claims.
Section 6.2. Description of Claim Administration Services. Without limiting the foregoing, the Administrator shall, consistent
with the past practices of the Company, to the extent such practices are compliant with applicable Law:
(a) provide claimants under the Administered Contracts and their authorized representatives (collectively, “Claimants”),
with Claim forms or with access to Claim forms available for download or printing via the Company’s website as allowed by
applicable Law, and provide instructions on how to submit a Claim upon request by such Claimants to Claimants in connection
therewith;
(b) establish, maintain and organize Claim files and maintain and organize other Claims-related records;
(c) receive, process, and evaluate Claims filed by or on behalf of Customers or Contract Holders, determine whether the
Claimant is eligible for benefits and if so, the nature and extent of such benefits, and pay such Claims in accordance with the terms
and conditions of the Administered Contracts and the Law or propose to deny, in accordance with the terms and conditions of the
Administered Contracts and the Law, or deny such Claims in whole or in part;
(d) provide Claimants with written notice of approval or disapproval of Claims and discharging other contractual
obligations under the Administered Contracts, including issuances of explanation of benefits and provider remittance advices;
(e) respond to all written or oral Claims-related communications that the Administrator reasonably believes to require a
response or as required by applicable Law;
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