Audit rights, data access and reporting

Contingency fee based audits are not supported by Claim Administrator. Audit samples will be limited to no more than three hundred (300) Claims.

Recorded reference: Page 5

Published rationale. An audit right exists but it is fenced on every side. Section 2.10 on pages 5 and 6 allows the Employer or an agent subject to the Claim Administrator's approval to audit on ninety days notice, bars contingency fee auditors, caps samples at three hundred claims, refuses reprocessing based on extrapolation, limits audits to one per twelve months and a two year lookback, charges all costs to the Employer and requires an Audit Agreement with a promise not to disclose proprietary information. Exhibit 7 Section 6(g) on pages 44 and 45 lets the Employer audit Prime only through the Claim Administrator, with records withheld where Prime is contractually prohibited and no material copied or removed. Reporting under Exhibit 1 on page 19 is standard format only, and Section 3.7 on page 7 excludes Business Confidential Information, which page 15 defines to include pricing and discounts, from the records the Employer may obtain. The model bars withholding data as proprietary; this text authorizes it, so bad.

Subject to the audit terms elsewhere in the Agreement, Employer may also audit Prime's records as they relate to the aforementioned Claims by coordinating such audit through Claim Administrator and executing an audit agreement with Prime as a party.

Recorded reference: Page 45

Published rationale. On Pages 5 and 6, Section 2.10 grants the Employer audit rights but restricts audits to one per year, caps sample sizes at 300 claims, prohibits contingency fee auditors and extrapolation, and requires 90 days advance notice. On Pages 44 and 45, Exhibit 7 allows audits of Prime records but requires coordination through the administrator, execution of an audit agreement, and payment of all costs, while prohibiting copying or removal of materials. These restrictions significantly impair full independent verification.

Audit samples will be limited to no more than three hundred (300) Claims.

Recorded reference: Page 5

Published rationale. Pages 5 and 6 permit employer or approved-agent claim payment audits, but require advance notice, a small sample, employer-paid costs, a separate audit agreement, restrictions on frequency and periods, and no reimbursement from extrapolated errors. Pages 44 and 45 add an indirect Prime inspection or audit route, with records withheld where Prime is legally or contractually prohibited and copying subject to approval. Page 19 offers standard reports, while customized reports can cost extra. These are real but constrained rights, so partial is more accurate than missing. They fall short of automatic comprehensive claims and financial feeds, unrestricted sponsor-selected auditors, pre-adjudication access and disclosure regardless of claimed proprietary status.

Contingency fee based audits are not supported by Claim Administrator. Audit samples will be limited to no more than three hundred (300) Claims.

Recorded reference: Page 5

Published rationale. Page 5 gives the Employer, or an agent subject to Claim Administrator's reasonable approval, a right to audit claim payment records on ninety days notice, during the term and for one hundred eighty days after termination. The right is heavily limited. Contingency fee audits are not supported. Samples are capped at three hundred claims. Extrapolation is barred on Page 5. The period is the current agreement year and the prior year, and no more than one audit in twelve months unless a government agency requires another. The auditor must agree not to disclose proprietary information. Pages 44 and 45 add a Prime records path, with copying forbidden without approval. Page 19 offers standard reports, not a full financial feed and not pre-adjudication access. Page 15 includes provider discounts and rates in business confidential information, which Page 7 can withhold. The model contract requires the plan's own auditor, scheduled claims and financial data without a request, pre-adjudication access, and no proprietary withholding. Audit rights exist and are materially weaker. That is partial.

Audit samples will be limited to no more than three hundred (300) Claims

Recorded reference: Page 5

Published rationale. The model term gives the plan audits with its own auditor, full claims level and financial data delivered on a schedule without asking, pre-adjudication access, and nothing withheld as proprietary. Audit rights exist here but are heavily fenced. Section 2.10 on pages 5 and 6 requires 90 days notice, Claim Administrator approval of the Employer's auditor, samples capped at 300 claims, no extrapolation from samples, at most one audit per 12 months, only the current and prior agreement year, Employer paid costs, and a signed audit agreement indemnifying the Claim Administrator. Exhibit 7 section 6(g) on pages 44 and 45 routes any audit of Prime through the Claim Administrator, requires Prime's audit agreement, and bars copying or removal of materials without approval. Standard reports are available at no charge on page 19. The rights are real but materially weaker than the model.