Self-Audit Reimbursement
Any Covered Individual who reviews eligible medical expenses and discovers an overcharge made by the medical facility or practitioner may provide the Group Benefits Administrator with a copy of the original billing, corrected billing and an explanation. The Covered Individual will be reimbursed 30% of the amount of savings generated. The reimbursement may not exceed the Covered Individual's calendar year deductible and out of pocket amount. To assist the Covered Individual with claim cost management, an Employee Audit Handbook tool has been developed to use as a guideline.

Patient Advocacy Program
TML IEBP's patient advocacy program is available to assist covered individuals in managing their out-of-pocket expenses.

Pre/Post Duplicate Claim Audit
TML IEBP has a software program that identifies duplicate billings at the line level of a claim. This automated process occurs before an analyst receives the claim. Therefore, a provider-billing duplicate is identified electronically and the error rate is decreased. Manual post duplicate audits are conducted to ensure duplicate payments are minimized.

Claim Liaison Audit
Claim audits are conducted when claim costs are considered to be in excess of usual and customary for the same services, in the same locality, under similar conditions. Special Audit Review is designed to verify the legitimacy of charges, treatments, procedures and confinements on any and all claims. The review identifies documentation discrepancies and provides an extensive analysis and documentation of the quantity, nature and intensity of services billed, severity of illness and unidentified and experimental therapies. An extensive clinical review using Interqual criteria to document quantity and quality of service measurements is conducted. The multi-page objective clinical review form has been designed to document inconsistencies in records and treatment protocols. Each physician and hospital bill is subjected to our Claims Edit System for unbundling and up-coding determination during the claim process.

Internal High Dollar Claim Audit
TML IEBP audits all claims in excess of $30,000.

External Claim Audit
An external claim audit is conducted on all Non-Network per diem hospital claims in excess of $20,000 and all Network non-case rate outpatient surgery claims in excess of $15,000.

Electronic Audit
TML IEBP maintains software programs that pre-screen network claims and pre/post screen out of network claims. The electronic screening audit assists in identifying provider billing procedures. Claims that pass the audits are sent for adjudication, claims that are identified as problematic are sent for review and adjudication.

Usual, Reasonable & Customary
Usual, Reasonable & Customary repricing will be used as a fee schedule for claims that are paid with no discount. If a non-network claim is reduced due to the usual and customary maximum the provider may balance bill the covered individual for the amount reduced. The covered individual may be responsible for payment of all or part of any fees for healthcare services not covered by your Health Benefit Plan because the services received are provided by health care providers who are not members of the plan's provider network. A usual, reasonable and customary charge is deemed to be 110% of the amount prescribed by the Centers for Medicare and Medicaid Services (CMS), RBRVS, other specialty CMS fee schedules and the Ingenix Essential RBRVS Fee Schedule.

Network Options
TML IEBP accesses the UnitedHealthcare Options PPO Network nationally under the United Medical Resource Alliance Agreement. The network extends from the metropolitan area into most of the rural Texas market areas. To manage the healthcare needs of the membership effectively, TML IEBP maintains a relationship with some providers directly to provide appropriate network coverage in some Texas counties. Please refer to www.tmliebp.org for an updated network listing.

A National Preferred Provider Network is available that provides cost-effective delivery of health care services. A three-tiered Preferred, Performance and Out-of-Network benefit option is also available. The Premium Provider Network provides premium delivery of health care services with evidenced based medicine and approved clinical protocols.

Transplant Network
A Transplant Network is available to TML IEBP Members, which includes services in Houston, Dallas and San Antonio. TML IEBP contracts with a national transplant network for out of state transplant needs.

Supplemental Network Repricing
Out of Network claims are repriced if Out of Network Providers participate in the Multi-Plan Supplemental Network. The discount amount will not be balance billed to the covered individual.

Professional Negotiation Service
Claims are reviewed against normative data ICD-9, CPT codes, and charges by revenue center to ensure that the ratios are appropriate and reasonable and are compared against a proprietary database. The cases are reviewed on an individual basis and the patient cannot be balance billed for the adjusted amount on the bill.

If Professional Negotiations cannot be provided, the out of network claim will be paid per the usual, reasonable & customary fee schedule and the covered individual may need to contact the Patient Advocacy program for balance billing assistance.

Preferred Lab
In order to manage laboratory costs and to improve healthcare benefits, TML IEBP has entered into agreements with Preferred Lab Sites and Laboratories. Preferred Lab services are offered throughout Texas with specific providers. The average savings with Preferred Lab utilization is 60%. Lab drawing sites can be accessed by visiting the TML IEBP website at www.tmliebp.org and selecting Preferred Laboratory under the Specialty drop-down menu in Provider Lookup.

Stop Loss/Reinsurance Interface
TML IEBP is an experienced administrator managing stop loss and is pre-approved with most major stop loss carriers. Monthly tracking reports are generated from the integrated billing, eligibility and claims administration system.

Public Employers Benefits Alliance (PEBA)
TML IEBP provides administrative support services to PEBA. Due to this administrative extension, TML IEBP's membership is not required to pay the PEBA participation or proposal fees, but maintains access to PEBA benefits.