4.9. SR 12-16-2013 - Laserfiche WebLink

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A Participant may apply to the Claims Administrator for reimbursement of eligible expenses incurred during such Plan Year (and applicable Grace Period) by completing a claim form and submitting such form(s) via interoffice mail or directly delivering the forms to the Claims Administrator (or its designee) setting forth at least the following: (a) the amount, date and nature of the expense, including the identity of the individual who incurred the expense; (b) the name of the person or entity to which the expense was paid; (c) the Participant's statement that the expense has not been reimbursed and the Participant will not seek reimbursement for the expense; and (d) such other information as the Claims Administrator may require. Such claim form shall be accompanied by bills, invoices, receipts, or other statements from an independent third party, or by an explanation of benefits ("EOB'� issued by a health plan, stating the eligible expense has been incurred and the amount of the expense. With respect to an over- the-counter drug or medicine (other than insulin) that constitutes an eligible expense under the Health Care Expense Reimbursement Plan or an over-the-counter drug or medicine for dental or vision care that constitutes an eligible expense under the Limited Scope Health Care Expense Reimbursement Plan, the claim form shall be accompanied by a copy of the prescription or a receipt identifying the purchaser of the drug or medicine (or the patient), the date and amount of the purchase, and an Rx number. The Claims Administrator is entitled to rely on the information provided on the claim form in processing claims under this Plan. Where circumstances beyond the Participant's control prevent submission within the described time frame, notice of a claim with an explanation of the circumstances may be accepted by the Claims Administrator as a timely filing. Claims shall be determined in accordance with this Article. 6.8 Determination of Claims and Review Procedure. (a) Third Party Benefits. The claims determination requirements and appeal procedures regarding benefits available from third parties shall be handled in accordance with the governing documents for those benefits. (b) Other Benefits. For benefits other than those described in (a), within thirty (30) days of receipt of a written claim for benefits, either the claim will have been paid or the Employer, or its designee, will notify the Participant that it has been denied. If the claim is denied, the Participant will be provided with the following information in writing: (i) the specific reasons for the denial; and, (ii) a description of any additional material or information necessary to complete the claim, and an explanation of why such material or information is necessary. 6.9 Authorization of Benefit Payments. The Plan Administrator shall issue directions to the Employer concerning all benefits to be paid from the Employer's assets pursuant to the provisions of the Plan, and shall warrant at the time the directions are provided that all such directions are in accordance with the Plan. 6.10 Benefit Payments. The Participant shall be reimbursed at least either (a) once per month; or (b) when the total reimbursement for eligible expenses first equals or exceeds a reasonable minimum amount that the Plan Administrator may communicate to Employees from time to time. 6.11 Overpayments. If a payment for benefits is made by the Plan in excess of the benefit to which a Covered Individual is entitled under the Plan, the Plan shall have the right to recover such overpayment from the payee. Repayment of an overpayment is a condition of participation in the Plan. ©2012 Hitesman&Wold, P.A. 17 City of Elk River Flexible Benefits Plan