Noblesville Schools Medical Plan 5 Claims Administrator and Plan Sponsor Responsibilities Claims Administrator and Plan Sponsor Responsibilities Determine Benefits Plan Sponsor and the Claims Administrator make administrative decisions regarding whether the Plan will pay for any portion of the cost of a health care service you intend to receive or have received. Plan Sponsor's and the Claims Administrator's decisions are for payment purposes only. Plan Sponsor and the Claims Administrator do not make decisions about the kind of care you should or should not receive. You and your providers must make those treatment decisions. Plan Sponsor and the Claims Administrator have the discretion to do the following: • Interpret Benefits and the other terms, limitations and exclusions set out in this SPD, the Schedule of Benefits and any SMMs and/or Amendments. • Make factual determinations relating to Benefits. Plan Sponsor and the Claims Administrator may assign this discretionary authority to other persons or entities including Claims Administrator's affiliates that may provide administrative services for the Plan, such as claims processing. The identity of the service providers and the nature of their services may be changed from time to time in Plan Sponsor's and the Claims Administrator's discretion. In order to receive Benefits, you must cooperate with those service providers. Process Payment for the Plan's Portion of the Cost of Covered Health Care Services The Claims Administrator processes the Plan's payment of Benefits for Covered Health Care Services as described in Section 1: Covered Health Care Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations. This means the Claims Administrator processes only the payment of the Plan's portion of the cost of Covered Health Care Services. It also means that not all of the health care services you receive may be paid for (in full or in part) by the Plan. Process Plan Payment to Network Providers It is the responsibility of Network Physicians and facilities to file for payment from the Plan. When you receive Covered Health Care Services from Network providers, you do not have to submit a claim to the Plan. Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers The Claims Administrator processes the Plan's payment of Benefits after receiving your request for payment that includes all required information. See Section 5: How to File a Claim. Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies The Claims Administrator adjudicates claims consistent with industry standards. The Claims Administrator develops its reimbursement policy guidelines, in its sole discretion, generally in accordance with one or more of the following methodologies: • As shown in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS).