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Master Application

Table of Contents

MASTER APPLICATION 1

SCHEDULE OF BENEFITS PRESCRIPTION DRUG DETAILS 29

SCHEDULE OF BENEFITS DENTAL DETAILS 35

SCHEDULE OF BENEFITS EXTENDED HEALTH DETAILS 43

NEW CLIENT ACCESS SERVICES 49

http://www.claimsecure.com 49

http://www.claimsecure.com/en/webreports/ 49

http://www.microsoft.com/ie 53

http://www.adobe.com/products/acrobat/readstep2.html 54

http://download2.citrix.com/FILES/en/products/client/ale/current/wfplug32.exe 54

EXISTING USER ACCESS SERVICES 55

SCHEDULE OF FEES 57

DEPOSITS 61

DECLARATIONS AND SIGNATURES 65

http://download2.citrix.com/FILES/en/products/client/ale/current/wfplug32.exe

http://www.adobe.com/products/acrobat/readstep2.html

http://www.microsoft.com/ie

http://www.claimsecure.com/en/webreports/

http://www.claimsecure.com/

SECTION A

CLIENT #GROUP #

Internal Use Only Master Application

1. LEGAL NAME ON CONTRACT: ____________

2. CLIENT NAME: Same as Legal Name on Contract or ____________

3. CLIENT INFORMATION:

Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Web Site Address Company E-mail Address

Client Contact:

Name Title Telephone Ext. Fax E-Mail Address

Executive Contact: Same as Above or


Nature of Business: (describe)

4. CONTRACTED PARTY INFORMATION: (if different from Client) (“Contracted Party”)

Name Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Web Site Address Company E-mail Address

Contracted Party Contact:


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SECTION A

CLIENT #GROUP #

Internal Use Only

5. CONSULTING/BROKERAGE FIRM: ____________

Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Web Site Address Company E-mail Address Contact Title Contact E-mail Address

6. THIRD PARTY ADMINISTRATOR/ INSURANCE COMPANY: ____________

Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Web Site Address Company E-mail Address Contact Title Contact E-mail Address

If address for Administration and Claims is different please specifyStreet Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Web Site Address Company E-mail Address Contact Title Contact E-mail Address

7. CONTRACT EFFECTIVE DATE:

12:01 am onDD MM YYYY

8. RENEWAL DATE:

12:01 am onDD MM YYYY

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SECTION A

CLIENT #GROUP #

Internal Use Only

9. PRESENT COVERAGE:Will the insurance applied for replace similar insurance? Yes No

Benefit Previous Insurer

Termination Date

Present Insurer

Renewal Date

Policy Number

Drug Dental Major Medical Hospital Vision Out of Country Health Spending Account Wellness Account Cost Plus Life A.D. & D. Vol. A.D.& D. Dependent Group Life (DGL)

Optional Life Spousal Optional Life Spousal Optional A.D.& D. Short Term Disability Long Term Disability

To avoid a period without coverage, do not terminate any existing coverage until notice has been given in writing that the coverage being applied for is approved by the Insurance Company.

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SECTION A

CLIENT #GROUP #

Internal Use Only

10. CLIENT INFORMATIONa) Client Name:Same as Client Name in item #1 or

____________b) Type of Account: ASO ASO with TPA services Insuredc) Enrolment Basis: Co-Ordination of Benefits

(listing all eligible dependents and spousal plan information)d) Certificate Numbers: Assigned by ClaimSecure

Payroll / Employee #’s (not to exceed 6 digits)e) Number of Lives: ____________ (initial enrolment) _______ Single _______

Familyf) List province(s) where employees reside:

British Columbia Alberta Manitoba Saskatchewan Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland Labrador Yukon Nunavut North West Territories

g) Initial Enrolment Information Via Future Enrolment Information Via

File Transfers Internet Keypunching E-mail File Transfers Diskettes E-mail Paper Diskettes

Paperh) Options

Drug Life Dental AD&D Major Medical Dependent Life Hospital Optional Life Vision Optional AD&D Out of Country Spousal Optional Life HSSA (Health Service Spending Account) Spousal Optional AD&D Wellness Account Short Term Disability Monitor (DUR) Long Term Disability Cost Plus Medical Management

Report (M.M.R.) Audit

Stop Loss Specify Limit: Rate: % of paid claims Provider:

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SECTION A

CLIENT #GROUP #

Internal Use Only

Client Access Services: If yes, refer to Section_C

Web Applications Yes No Online Reporting Yes No Claims Extract Yes No

New Client: Yes No If Yes complete Section C1

Existing Client: Yes No If Yes Complete Section C2

10. PAY DIRECT CARD INFORMATIONClient Name/Logo Yes No Insurer Logo Yes No Other Logo Yes No Specify: _______________________Sample Logo on File Yes No Specify: _______________________Spencer Vision Yes No ClaimSecure Card Yes No Other Card Yes No Specify: _______________________

11. MAILING ADDRESS FOR CARDS

Initial set of cards to be forwarded to:Address/Contact (if different from Client)

New & Replacement Cards/Certificates to be forwarded to:Address/Contact (if different from Above)

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SECTION A

CLIENT #GROUP #

Internal Use Only

12. DIVISION AND UNIT STRUCTURE

Division Unit Policy # Language Division / Unit Description Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr. Eng. Fr.

If address for the division/unit(s) is different, please complete this section:Division/Unit: Name Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Contact Title Contact E-mail Address

Division/Unit: Name Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Contact Title Contact E-mail Address

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SECTION A

CLIENT #GROUP #

Internal Use Only Schedule of Benefits

13. DRUG BENEFIT Yes No Refer to Section B.1 for Standard

Plans

Indicate Division Indicate Unit

a) Annual Deductible Yes No If applicable: Single Family

Calendar Year Policy Yearb) Co-Payment

If co-payment consists of both a dollar amount and %, please indicate if the % is based on the:

Ingredient AmountGross AmountBalance Amount

Compound Claims:If co-payment includes a dispensing fee please specify the co-pay for compound claims

Flat Dollar Percentage

Multi-tier Co-payment:Single FamilyCalendar Year Policy Year

c) Plan Type d) Mail Order / PPO Yes No

Indicate co-payment if different from (b)Provide details:

e) Maximum Yes No If applicable: Single Family If Maximum is other than unlimited is it

Lifetime Calendar Year Policy Year

f) Maximum Dispensing Fee Allowance ($) $ $ $ $ $ $

g) Benefit Maximum Age h) Dependent Maximum Age i) Student Maximum Age

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SECTION A

CLIENT #GROUP #

Internal Use Only

Plan Modifications – Indicate below any modifications to standard plan chosen. Indicate maximum(s) if applicable.

Inclusions: Exclusions: Special Authorization only:

NOTE: Where coverage specifications differ between the “Schedule of Benefits” and the “Plan Modifications” areas, the specifications under Plan Modifications will apply.

WAITING PERIOD(Length of time employees must be employed by the Plan Sponsor to be eligible for coverage)


a) Timeframe (specify) b) Of continuous employment

(Y/N)

c) If not continuous employment describe below:

d) Applies to present and future employees?

e) Applies to future employees only?

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SECTION A

CLIENT #GROUP #

Internal Use Only 14.DENTAL BENEFIT Yes No

Refer to Section B.2 for Standard Plan


a) Benefit Period

Calendar Year Policy Yearb) Annual Deductible Yes No

If applicable: Single FamilyCalendar Year Policy Year

c) Recall Frequency: ( ) mths d) Fee Guide Year: choose one of the following:

Fixed (indicate “F” and year) Current Year (indicate “C”) Lagging Fee Schedule (indicate “L” and # yrs)

e) Specialist Dental Fees covered

Yes No f) Level 1: Basic Restorative: Co-payment % g) Coverage for white fillings on molar teeth

Yes No

h) No. of allowable scaling units ( ) based on: Calendar Year Policy Year

12 Consecutive Months ( )

i) Level 2: Perio & Endo: Co-payment % j) Level 3: Major Restorative: Co-payment % k) Missing tooth exclusion applicable.

Yes No

l) Crowns, bridges, denture replacement Frequency: ( ) yrs

m) Annual $ Maximum: Level 1 $ $ $ $ $ $

n) Annual $ Maximum: Level 2 $ $ $ $ $ $

o) Annual $ Maximum: Level 1 & 2 Combined $ $ $ $ $ $

p) Annual $ Maximum: Level 3 $ $ $ $ $ $

q) Annual $ Maximum: Level 1, 2, & 3 Combined $ $ $ $ $ $

r) Annual $ Maximum: Other $ $ $ $ $ $

s) Level 4: Orthodontics: Co-payment %

t) Lifetime $ Maximum: Level 4 $ $ $ $ $ $

u) Age Max. for Orthodontic Yes No

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SECTION A

CLIENT #GROUP #

Internal Use Only If yes, indicate maximum age

v) Overall Lifetime $ Maximum Yes No $ $ $ $ $ $

If yes, indicate amount $

w) Benefit Maximum Age x) Dependent Maximum Age y) Student Maximum Age

Plan Modifications – Indicate below any modifications to standard plan beside the applicable level. Changes can be included on a separate document.





(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only 15.EXTENDED HEALTH BENEFIT

Major Medical Benefit Yes No Hospitalization Benefit Yes No Vision Benefit Yes No Vision Preferred Provider Yes

No Refer to Section B.3 for Standard Plan


a) Benefit Period

Calendar Year Policy Yearb) Annual Deductible Yes No

If applicable: Single FamilyCalendar Year Policy Year

** If Annual EHB Deductible exists – does it incl.Major Medical Yes No

Hospital Yes No Vision Yes No

c) Co-payment Yes No Major Medical

Hospital Vision

d) Overall Lifetime EHB Max. Yes No Includes: Major Medical Yes No


e) Annual Maximum Yes No If applicable: Single Family

Calendar Year Policy YearIncludes: Major Medical Yes No


f) Benefit Maximum Age g) Dependent Maximum Age h) Student Maximum Age i) Vision PPO –Premium Rate

per member per month $ $ $ $ $ $

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SECTION A

CLIENT #GROUP #

Internal Use Only

Plan Modifications – Indicate below any modifications to standard plan. Changes can be included on a separate document.





(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

16.OUT OF COUNTRY (O.O.C.) Yes No

Provider:


a) Trip Duration For Active Employees under age 70 (Indicate number of days)

b) Trip Duration For Active Employees age 70 and over and ALL Retirees (Indicate 30 or 60 days)

e) Stabilization Period for retirees and activeEmployees 70 and over (Indicate 3 or 6 mths)

f) Benefit Maximum Age g) Dependent Maximum Age h) Student Maximum Age i) Unit Premium Rate Single $

Family $




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

17. HEALTH SERVICE SPENDING ACCOUNT (HSSA) Yes No


a) Benefit Period Calendar Year Policy Year b) Calculation : Manual Formula

If Formula, enter the dollar amount ( )

c) Frequency Annual Semi Annual Quarterly Every 3 months Bi-Monthly Monthly d) Pro-rating required for initial enrolment

Yes No

e) Pro-rating for new employees

Yes No f) Prior Period Grace (provide number of days) g) Termination Age h) Carry forward Credit (Dollars)

Yes No




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

18. WELLNESS ACCOUNT Yes No


a) Benefit Period Calendar Year Policy Year b) Calculation : Manual Formula

If Formula, enter the dollar amount ( )

c) Frequency Annual Semi Annual Quarterly Every 3 months Bi-Monthly Monthly d) Pro-rating required for initial enrolment

Yes No

e) Pro-rating for new employees

Yes No f) Termination Age g) Benefit Termination at Retirement

Yes No




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

Complete the following only if ClaimSecure is providing Third Party Administrative(TPA) Services for benefits such as Life, AD&D, LTD, Dependent Group Life, etc.

19.EMPLOYEE LIFE BENEFIT Yes No Insurance Carrier:

Policy #:


a) Life Schedule b) Life $ Maximum Amount $ $ $ $ $ $ c) NEM (Non Evidence Maximum) $ $ $ $ $ $ d) Reduction Schedule e) Benefit Maximum Age f) Member Contribution Life g) Unit Premium Rate Life

(per $1,000 of Insurance)

Note: Life Volume Rounding to the next $1000




(Y/N)



** For further details regarding the Risk Benefits, please refer to the Insurance Contract **

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SECTION A

CLIENT #GROUP #

Internal Use Only

20.EMPLOYEE ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) Yes No Insurance Carrier:

Policy #:


a) AD&D Schedule b) AD&D $ Maximum Amount $ $ $ $ $ $ c) NEM (Non Evidence Maximum) $ $ $ $ $ $ d) Reduction Schedule e) Benefit Maximum Age f) Member Contribution AD&D g) Unit Premium Rate AD&D

(per $1,000 of Insurance)

Note: AD&D Volume Rounding to the next $1000




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

21.DEPENDENT GROUP LIFE BENEFIT (DGL) Yes No Insurance Carrier:

Policy #:


a) Spouse Amount b) Child Amount. c) Include Dep. AD&D (Y or N)? d) Benefit Maximum Age e) Member Contribution f) Unit Premium Rate




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only

22.EMPLOYEE OPTIONAL LIFE BENEFIT Yes No Insurance Carrier:

Policy #:


a) Optional Life Schedule b) Optional Life $ Max. Amount $ $ $ $ $ $ c) Reduction Schedule d) Benefit Maximum Age e) Member Contribution

Optional Life (rate per $1,000)

Age Band Smoker Male Smoker Female Non-smoker Male Non-smoker Female

Under 35 35-39 40-44 45-49 50-54 55-59 60-64

No Age Band

If Age Band differs from the above standard plan, please indicate modifications below:



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SECTION A

CLIENT #GROUP #

Internal Use Only

23.EMPLOYEE OPTIONAL AD&D BENEFIT Yes No Insurance Carrier:

Policy #:


a) Optional AD&D Schedule b) AD&D $ Maximum Amount $ $ $ $ $ $ c) Reduction Schedule d) Benefit Maximum Age e) Member Contribution

Optional AD&D (rate per $1,000)


Under 35 35-39 40-44 45-49 50-54 55-59 60-64

No Age Band




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SECTION A

CLIENT #GROUP #

Internal Use Only

24.SPOUSAL OPTIONAL LIFE BENEFIT Yes No Insurance Carrier:

Policy #:


a) Spousal Opt. Life Schedule b) Spousal Opt. Life

$ Max./Min. Amount $ $ $ $ $ $

c) Reduction Schedule d) Benefit Maximum Age e) Member Contribution

Spousal Optional Life (rate per $1,000)


Under 35 35-39 40-44 45-49 50-54 55-59 60-64

No Age Band




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SECTION A

CLIENT #GROUP #

Internal Use Only

25.SPOUSAL OPTIONAL AD&D Yes No Insurance Carrier:

Policy #:


a) Spousal Opt. AD&D Schedule b) Spousal Opt. AD&D

$ Max./Min. Amount $ $ $ $ $ $

c) Reduction Schedule d) Benefit Maximum Age e) Member Contribution

Spousal Optional AD&D (rate per $1,000)


Under 35 35-39 40-44 45-49 50-54 55-59 60-64

No Age Band




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SECTION A

CLIENT #GROUP #

Internal Use Only

26.SHORT TERM DISABILITY BENEFIT Yes No Insurance Carrier:

Policy #:


a) Percentage of Weekly Salary b) Maximum Weekly Benefit c) Injury Elimination Period

(days)

d) Sickness Elimination Period(days)

e) 1st Day Hospitalization

Yes No

f) Maximum Benefit Period (days) g) Benefit Maximum Age h) Member Contribution i) Unit Premium Rate

(per $10 of Insurance)

Note: STD Volume Rounding to the next $10




(Y/N)




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SECTION A

CLIENT #GROUP #

Internal Use Only 27.LONG TERM DISABILITY BENEFIT Yes No

Insurance Carrier: Policy #:


a) % of Monthly Salary, or Graded Scale. Indicate Scale below

b) Maximum Monthly BenefitAll Sources

Yes No c) NEM (Non Evidence Maximum) $ $ $ $ $ $ d) Injury Elimination Period

(days)

e) Sickness Elimination Period(days)

f) Maximum Benefit Period

g) Own Occupation Period h) CPP/QPP Integration

(Primary, Secondary, None)?

i) Benefit Maximum Age j) Member Contribution k) Unit Premium Rate

(per $100 of Insurance)

Note: LTD Volume Rounding to the next $100 Graded Scale (if appl.) % of the first $ , % of the next $ , and % of the excess.




(Y/N)




28. PARTICIPATIONParticipation under this Plan is: Mandatory Non-Mandatory

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SECTION A

CLIENT #GROUP #

Internal Use Only If participation is Mandatory, 100% of all eligible employees who are actively at

work must be insured for all benefits for which they are eligible. If your plan is 100% employer paid, it is a mandatory plan.

If participation is Non-Mandatory, an eligible employee is allowed to refuse all coverage under the Policy, subject to the minimum participation requirements of the Policy. An Employee refusing coverage under the Policy must refuse all coverage.

If the Policy includes Extended Health and/or Dental Benefits, an eligible employee may waive coverage for these benefits if insured for similar coverage under their spouse’s plan. Such waivers will not affect the participation level.

29. DISABLED EMPLOYEESIs any employee currently absent from work due to sickness or injury, or has any employee been absent from work due to any one disability for 14 consecutive days in the past, 12 months, or, has any employee been absent from work on 6 or more occasions over the past 12 months?

Yes No If “Yes”, list the employee(s):Employee Name Certificate Number Premium Waiver Approved Yes No

Yes No

Yes No

Yes No

Yes No

30. GRANDFATHERED AMOUNTSAny amounts of Employee Life, Accidental Death and Dismemberment, Short Term Disability or Long Term Disability Insurance which are to be grandfathered require proof of prior coverage. For Long Term Disability, attach a copy of the approval letter from the prior carrier. For all coverage’s, attach a recent billing from the prior carrier. Grandfathered amounts cannot be honoured unless proof that is satisfactory to ClaimSecure is received.

31. PREVIOUS BILLINGA copy of the Previous Billing must be included with this Master Application for reference.

32. INSURANCE CONTRACTA copy of the Insurance Contract must be included with this Master Application for reference.

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SECTION A

CLIENT #GROUP #

Internal Use Only

33. LIABILITY AND INDEMNIFICATION

The following statement shall govern liability and indemnification against harm or loss:

‘ClaimSecure neither insures nor underwrites any of the insurance issued to the client. The client shall indemnify and hold ClaimSecure harmless against any claim, loss, liability, suit or judgement based on a claim by an eligible employee, member or dependent’

34. ORIGINAL ENROLMENT APPLICATION FORMSWhen ClaimSecure is providing TPA Services on benefits such as Life, AD&D, LTD, etc, original applications must be securely maintained. As most clients request to maintain these originals, the following confirmation letter must be completed and authorized by the Client.

35. AUTHORIZED SIGNATURE: ______________________________________

DATE: ______________________________________

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SECTION A

CLIENT #GROUP #

Internal Use Only

** ONLY APPLICABLE FOR TPA CLIENTS **

Insert Date Here

ClaimSecure Inc43 Elm Street, Suite 200Sudbury, OntarioP3C 1S4

To Whom It May Concern

Re: Insert Group Name Here – Group # Insert ClaimSecure Group Number Here

Please accept this letter as our acceptance to maintain and assume full responsibility of the original benefit enrolment forms on behalf of our employees and their dependents enrolled under the above ClaimSecure Program.

With the above declaration, it is understood that ClaimSecure is released from any and all responsibility relating to the original enrolment material.

Dated this _______ day of ___________________________ 2003.

Contracted Party

Per:_______________________________ Per: ________________________________Authorized Signatory Print Name

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SECTION A

CLIENT #GROUP #

Internal Use Only

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SECTION B.1

CLIENT #GROUP #

Internal Use Only

Schedule Of Benefits Prescription Drug Details

(if coverage is applicable)

PLAN A - PRESCRIPTION DRUG PLANPLAN AG - GENERIC PRESCRIPTION DRUG PLAN

This plan covers the cost of the following drugs:

All drugs which by law or convention* requires a physician's or dentist's prescription Insulin supplies which includes needles, syringes and diagnostic tests. This excludes

swabs, rubbing alcohol, lancets, control solution, etc. All injectibles including serums, vaccines, and injectible vitamins Extemporaneous compounds prepared by a pharmacist

Exclusions Any drug or medication which may be purchased without a prescription. This further

excludes over-the-counter (O.T.C.) products whether prescribed or not. Fertility drugs are not covered even if prescribed for therapeutic use Anabolic steroids are not covered even if prescribed for therapeutic use Anti-Smoking agents are not covered even if prescribed for therapeutic use Items deemed cosmetic even if a prescription is legally required

As a further guide, the plan excludes in part:

Vitamins (except injectible vitamins) Patented Medicines and G.P. Products First aid and surgical supplies Atomizers, vaporizers Salt and sugar substitutes Infant formula, dietary foods and aids Contact lens care products Diagnostic aids and laboratory tests Contraceptives other than oral Lozenges, mouthwash, toothpaste and cosmetics Non-medicated shampoos, skin cleansers, skin protectors, emollients and soaps Any benefit provided by a Government plan

NOTE: In the case of a Generic Plan, the pharmacist will only be reimbursed for the lowest priced

substitutable drug, as provided for in the Provincial Drug Benefit Formulary.

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SECTION B.1

CLIENT #GROUP #

Internal Use Only

PLAN B - PRESCRIPTION DRUG PLANPLAN BG - GENERIC PRESCRIPTION DRUG PLAN


All drugs which by law or convention* requires a physician's or dentist's prescription Insulin supplies which includes needles, syringes and diagnostic tests. This excludes

swabs, rubbing alcohol, lancets, control solution, etc. All injectibles including serums, vaccines, and injectible vitamins Extemporaneous compounds prepared by a pharmacist Hematinic vitamins properly identified in the Compendium of Pharmaceuticals and

Specialties Most commonly prescribed over-the-counter (O.T.C.) products

Exclusions Fertility drugs are not covered even if prescribed for therapeutic use Anabolic steroids are not covered even if prescribed for therapeutic use Anti-Smoking agents are not covered even if prescribed for therapeutic use Items deemed cosmetic even if a prescription is legally required


Vitamins (except injectible vitamins) Patented Medicines and G.P. Products First aid and surgical supplies Atomizers, vaporizers Salt and sugar substitutes Infant formula, dietary foods and aids Contact lens care products Diagnostic aids and laboratory tests Contraceptives other than oral Lozenges, mouthwash, toothpaste and cosmetics Non-medicated shampoos, skin cleansers, skin protectors, emollients and soaps Any benefit provided by a Government plan



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SECTION B.1

CLIENT #GROUP #

Internal Use Only

PLAN C - PRESCRIPTION "PLUS" DRUG PLANPLAN CG - GENERIC PRESCRIPTION "PLUS" DRUG PLAN


All drugs which by law or convention* requires a physician's or dentist's prescription Insulin supplies which includes needles, syringes and diagnostic tests. This

excludes swabs, rubbing alcohol, lancets, control solution, etc. All injectibles including serums, vaccines, and injectible vitamins Extemporaneous compounds prepared by a pharmacist Hematinic vitamins properly identified in the Compendium of Pharmaceuticals and

Specialties Most commonly prescribed over-the-counter (O.T.C.) products Most vitamins

Exclusions Fertility drugs are not covered even if prescribed for therapeutic use Anabolic steroids are not covered even if prescribed for therapeutic use Anti-Smoking agents are not covered even if prescribed for therapeutic use Items deemed cosmetic even if a prescription is legally required


Patented Medicines and G.P. Products First aid and surgical supplies Atomizers, vaporizers Salt and sugar substitutes Infant formula, dietary foods and aids Contact lens care products Diagnostic aids and laboratory tests Contraceptives other than oral Lozenges, mouthwash, toothpaste and cosmetics Non-medicated shampoos, skin cleansers, skin protectors, emollients and soaps Any benefit provided by a Government plan



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SECTION B.1

CLIENT #GROUP #

Internal Use Only

PLAN COMPARISON

ClaimSecure also offers the following plan designs with inclusions and/or exclusions to the above mentioned Standard Prescription Drug Plans A, B or C.

PLANTYPE

EQUIVALENT TO BASIC PLAN

PLAN EXCLUSIONS PLAN INCLUSIONS

D Plan B Anti-Smoking AgentsFertility DrugsLancetsSteroids

E Plan A Convention Drugs(unless life sustaining)

Anti-Smoking AgentsFertility DrugsLancetsSteroids

F Plan A Convention Drugs(except all forms of nitro-glycerine)

LancetsSteroids

H Plan A Convention Drugs(except all forms of nitro-glycerine)Oral Contraceptives

LancetsSteroids

J Plan A Convention Drugs(unless life sustaining)

Anti-Smoking AgentsFertility DrugsLancetsSteroids

K Plan A Oral Contraceptives SteroidsL Plan A Convention Drugs

(unless life sustaining)LancetsSteroids

M Plan C Anti-Smoking AgentsFertility DrugsLancetsSteroids

O Equivalent to currentProvincial Drug

FormularyQ Plan A Convention Drugs

Preventative Vaccines(including Hepatitis)

R Plan A AccutaneConvention Drugs(unless life sustaining)OTC Injectible VitaminsPreventative Vaccines

Hepatitis B Vaccine

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SECTION B.1

CLIENT #GROUP #

Internal Use Only

PLAN COMPARISON

PLANTYPE

EQUIVALENT TO BASIC PLAN

PLAN EXCLUSIONS PLAN INCLUSIONS

S Plan A Injectable VitaminsPreventative Vaccines(including Hepatits)

T Plan A Client Specific Managed Plan (closed)All new drugs released after April 17/95 (unless cov’d by ODB)

New generic drugs released on or after April 17/95 (if the brand name is eligible)LancetsSteroids

U Plan A EmollientsHematinic VitaminsLaxativesShampoos (all)Skin CleansersSkin ProtectorsSoaps

3 None Client Specific Managed Plan (closed)National Formulary

Only drugs listed on National Formulary

4 None Client Specific Managed Plan (closed)Used to administer two tier co-pay(unless life sustaining)

Only drugs specified by administrator

7 Plan A Managed Formulary (general)All new drugs released after March 1/02

New generic drugs released on or after March 1/02 (if the brand name is eligible)

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SECTION B.1

CLIENT #GROUP #

Internal Use Only

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

Schedule Of Benefits Dental Details


ClaimSecure shall pay the lesser of the reasonable and customary charge of the Dentist or Dentist Specialist and the charges specified in the suggested provincial Fee Schedule for the dental services when the dental services are:

- necessary Dental Services defined as dental services that are consistent with the diagnosis and treatment of the condition and in accordance with standards of good dental practice.

- not covered or eligible for coverage by a government program or plan- subject to all applicable limitations, exclusions and maximum benefit limits and any deductible or co-insurance specified in the Master Application. - incurred while you are eligible under this benefit.- provided by a dental provider licensed to practice in the province where the services are performed. A dental provider may be a licensed dentist, dentist specialist or denturist.

If the specialist dental fee schedule option is not included, services rendered by a Dentist Specialist will be paid in accordance with the suggested provincial fee schedule for general practice Dentists.

Fee schedule means the schedule of fees approved and published by a provincial dental association and stipulated for use under this Benefit Plan in the Master Application. When treatment outside Canada is necessary, the approved fee schedule used will be the fee schedule of the province of residence in which the covered person resides.

When a planned course of dental treatment is expected to exceed $1500 or more, it is highly recommended that ClaimSecure receive a predetermination of benefits from the attending dental provider. This predetermination will include a description of the proposed treatment, an estimate of the charges for services and dental radiographs where applicable. ClaimSecure will determine and confirm the amount of approved benefits.

LEVEL 1Level 1 services include Diagnostic, Preventive, Minor Restorative, Minor Oral Surgical, Maintenance only of Prosthetic Denture and Denture Maintenance, and Adjunctive Services.

Diagnostic Services are services to diagnose a dental condition.The following diagnostic services are covered:

complete examination. Limitation: one (1) complete examination every thirty-six (36) consecutive months.

recall examination. Limitation: one (1) recall examination every recall period as specified Section A. #14c.

specific examination. Limitation: two (2) specific examinations every twelve (12) consecutive months.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

emergency examination.Limitation: two (2) emergency examinations every twelve (12) consecutive months.

complete series of radiographs or panoramic radiograph.Limitation: one (1) complete series or panoramic radiograph every thirty-six (36) consecutive months.

bite-wing radiographs.Limitation: one every twelve (12) consecutive months.

bacteriological tests/analyses. histopathological tests/analyses. microbiological tests/analyses. occlusal radiographs. periapical radiographs.

Preventive Services are services to prevent future dental problems.The following preventive services are covered:

fluoride.Limitation: one (1) fluoride treatment every recall period as specified in Section A.

#14c. oral hygiene instruction.

Limitation: one (1) occurrence per lifetime. polishing.

Limitation: one (1) unit of polishing every recall period as specified in Section A. #14c. scaling/root planing.

Limitation: the number of units specified in Section A. #14h. interproximal disking. pit & fissure sealants. space maintainers & maintenance of space maintainers.

Minor Restorative services are services to repair teeth.The following minor restorative services are covered:

amalgam restorations.Limitation: non-bonded amalgam restorations. Bonded amalgam restorations are paid up to the cost of non-bonded amalgam restorations.

prefabricated restorations (prefabricated crowns).Limitation: Primary Teeth only.

tooth coloured restorations.Limitation: (If specified in Section A. #14g, limited to anterior and bi-cuspid teeth only. Tooth coloured restorations performed on molar teeth are reduced to the cost of non-bonded amalgam restorations).

caries/trauma/pain control. prefabricated posts. retentive pins.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

Minor Oral Surgical services include oral surgery services.The following minor oral surgical services are covered:

alveloplasty – simple. antral surgery. extractions & residual root removal. fractures. frenectomy. hemorrhage control. surgical excision. surgical exposure. surgical incision. treatment of salivary glands. vestibuloplasty.

Crown/Bridge/Denture Maintenance services include services for the repair of prosthetic appliances.The following maintenance services are covered:

denture rebase.Limitation: one (1) per arch every thirty-six (36) consecutive months.

denture reline.Limitation: one (1) per arch every thirty-six (36) consecutive months.

denture repair. recementation of crowns/bridgework. repair of crowns/bridgework.

Adjunctive services include services that are not classified elsewhere.The following adjunctive services are covered:

deep sedation. general anaesthesia. nitrous oxide. nitrous oxide with oral sedation. parenteral conscious sedation. therapeutic injections.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

LEVEL 2Level 2 Services include Endodontics and Periodontics.

Endodontic services include services to treat the pulp chamber of the tooththe following endodontic services are covered:

root canal therapy.Limitation: routine initial root canal therapy. Complicated root canal therapy reduced to cost of routine root canal therapy. Retreatment of root canal is covered only if at least thirty-six (36) consecutive months have elapsed from the date of the initial root canal therapy. No coverage for primary teeth.

apexification. apicoectomy. bleaching of endodontically treated teeth. hemisection. intentional removal and implantation. isolation of endodontic tooth. open & drain. pulpectomy. pulpotomy. retrofilling. root amputation.

Periodontic services include services to treat the tissue supporting the teeth.The following periodontic services are covered:

periodontal appliances and maintenance.Limitation: one (1) appliance per arch every thirty-six (36) consecutive months.

management of oral disease. occlusal equilibration. periodontal abscess or periocoronitis. periodontal surgery – flap approach – osteoplasty. periodontal surgery – flap approach – osseous defect. periodontal surgery – gingival curettage. periodontal surgery – gingivoplasty. periodontal surgery – gingivectomy. periodontal surgery – grafts – soft tissue. proximal wedge.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

LEVEL 3Level 3 services include Major Restorative and Major Oral Surgical Services.

Major RestorativeThe following major restorative services are covered:

INLAYS/ONLAYS/CROWN- inlays – metal, composite, porcelain.- onlays – metal composite, porcelain.- prosthodontic examinations.- acrylic crowns.- porcelain/ceramic crowns.- ¾ porcelain/ceramic crowns.- cast metal crowns.- ¾ cast metal crowns.- gold foil restorations.- cores – amalgam and tooth coloured.- equilibration casts.- posts, cores and posts & cores.- retentive pins for inlays, onlays & crowns.

DENTURES- complete dentures. Limitation: standard complete dentures.- cast partial dentures including partial dentures with clasps and/or rests.- overdentures and complicated dentures reduced to the cost of standard dentures.- partial acrylic dentures including partial dentures with clasps and/or rests.

BRIDGEWORK- cast metal pontics.- porcelain/ceramic pontics.- acrylic retainers.- porcelain/ceramic retainers.- cast metal retainers.- ¾ cast metal retainers.- metal, composite and porcelain inlay retainers.- metal, composite and porcelain onlay retainers.- retentive pins for inlay/onlay retainers.- replacement frequency for inlays, onlays, crowns, bridgework and

dentures asspecified in Section A. #14-l. The initial placement of dentures and bridgework may not be covered if at least one tooth to be replaced is not extracted while the member was covered by the employer’s dental plan if specified in Section A. #14k.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

Major SurgeryThe following major oral surgery services are covered:

alveoloplasty (not performed in conjunction with extractions). crown lengthening. mandibulectomy. maxillectomy. reconstruction. remodelling floor of mouth. sequestrectomy. surgical movement of teeth.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

LEVEL 4

Level 4 Services include Orthodontics.

Orthodontics The following orthodontic services are covered:

cephalometric radiographs. diagnostic photographs. enucleation. full orthodontic treatment. hand & wrist radiographs. interpretation from other source. monthly payments. oral surgery performed in conjunction with orthodontics. These services will be

evaluated on a case by case basis. orthodontic examinations. orthodontic casts. surgical exposure. tracing & interpretation.

General Limitations & Exclusions for Dental BenefitsIn addition to the limitations and exclusions of this Benefit Plan, and those limitationsand exclusions contained in the description of the benefits, the dental benefits do not cover the following:

charges for services provided for cosmetic reasons only, except for orthodontic services when such services are included in the orthodontic services benefit in the schedule of dental benefits and orthodontic services are included under this benefit plan.

charges for missed or cancelled appointments, completion of forms, communications, or any other non-treatment services.

charges for services or supplies that are not necessary dental services or do not meet accepted standards of dental practice.

under this benefit charges which are covered under any other benefit in this benefit plan.

professional fees for an anaesthetist. replacement of lost, stolen or broken prostheses or appliances. protective appliances for athletic purposes. implants and any dental service associated with implants.

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SECTION B.2

CLIENT #GROUP #

Internal Use Only

services covered by any Workplace Safety and Insurance Board unless prohibited by any Government legislation.

services and supplies not shown in the included list of benefits. any claim expense or service provided by an immediate family member are not

eligible for coverage/payment . dental services or supplies required as a result of war, terrorism, rebellion or

hostilities of any kind, whether or not the covered person is a participant. dental services or supplies required as a result of participation in a riot or civil

disturbance. dental services or supplies due to intentional self-inflicted injury.

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SECTION B.3

CLIENT #GROUP #

Internal Use Only Schedule Of Benefits

Extended Health Details


The Client shall pay reasonable and customary charges in the geographic area where the claim occurs, for the services, supplies and equipment set out below when the services, supplies and equipment are:

- ordered by a physician or other health care provider. A physician means a doctor of medicine who is legally qualified to practice medicine or surgery and is licensed by the appropriate board in the jurisdiction where his or her services are rendered. A health care provider is defined as a licensed, certified, registered or chartered practitioner licensed to practice in the jurisdiction where the services are provided.

- medically necessary services defined as services, equipment or supplies consistent with the diagnosis and treatment of the condition and in accordance with the standards of good medical practice. The order, recommendation or approval of a physician does not make the service medically necessary

- not covered or eligible for coverage by any government program or plan.- subject to all applicable limitations, exclusions and maximum benefit limits and any

deductible or co-insurance specified in the Master Application.

- must be incurred while you are eligible under this benefit.

The Benefit period refers to the period specified in Section A #15a.

PARAMEDICAL SERVICESServices provided by the following licensed, certified or registered professional Paramedical Practitioners, providing the services are within the scope of their profession.Note: Eligible expenses are limited to one professional visit per day for each type of practitioner.Payment can be issued on first dollar claims excluding provinces where the Provincial Health Insurance Plan prohibits this by law. X-ray examinations provided by a licensed chiropractor, osteopath practitioner, chiropodist and podiatrist are eligible and included in the benefit maximum.

AcupunctureMaximum Benefit $500.00 per benefit period per covered person.

Chiropodist/PodiatristCombined Maximum Benefit $500.00 per benefit period per covered person.

ChiropractorMaximum benefit $500.00 per benefit period per covered person.

Massage TherapyMaximum Benefit $500.00 per benefit period per covered person.Note: A physician’s referral is required.

NaturopathMaximum Benefit $500.00 per benefit period per covered person.Exclusions: Homeopathy is not covered. Supplements and remedies are not covered.

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SECTION B.3

CLIENT #GROUP #

Internal Use Only

OsteopathMaximum Benefit $500.00 per benefit period per covered person.

PhysiotherapyMaximum Benefit $500.00 per benefit period per covered person.Note: A physician’s referral is required.

PsychologistMaximum Benefit $500.00 per benefit period per covered person.

Speech TherapyMaximum Benefit $500.00 per benefit period per covered person.Note: A physician’s referral is required.

PRIVATE DUTY NURSING Services of a Registered Nurse, Licensed Practical Nurse, or Registered Nursing AssistantMaximum Benefit $10,000.00 per benefit period per covered person. Note: The Nursing Provider may not be a resident of the Participant’s home or related to the Participant’s family.Services must be determined to be medically necessary and must be provided in a Participant’s home. Services rendered must require the skill of a Registered Nurse, Licensed Practical Nurse or Registered Nursing Assistant. Services must be pre-approved by ClaimSecure with such approval being subject to periodic reassessment.

AMBULANCE SERVICECharges for Ground Ambulance Service to the nearest Hospital or other medical facility capable of providing the required care.Note: Emergency transportation by air, rail or water may be considered. Pre-approval by ClaimSecure is required. Limitations may apply. Only charges for uninsured amounts will be considered.

ACCIDENTAL DENTALCharges for the services of a licensed dental provider for the repair or replacement of sound natural teeth when caused by an external force or blow to the face. Services rendered must be within twelve (12) consecutive months of the date of the accident. Note: Pre-approval by ClaimSecure is required.

HEARING AIDSThe purchase of a new hearing aid(s) or repair of an existing hearing aid(s).Maximum Benefit $500.00 every sixty (60) consecutive months per covered person.Note: A Physician or Audiologist’s referral is required for the purchase of a hearing aid. Provincial assisstive device program maximums will be taken into consideration where applicable. Exclusions: Hearing tests, batteries and ear moulds are not covered.

ORTHOTICSCustom Moulded Orthotics Maximum Benefit of $400.00 per benefit period per covered person.Note: Physician’s or Chiropodist/Podiatrist’s referral required.

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SECTION B.3

CLIENT #GROUP #

Internal Use OnlyCUSTOM MADE ORTHOPAEDIC SHOESCustom Fitted Orthopaedic Shoes. Maximum Benefit of $400.00 every thirty-six (36) consecutive months per covered personNote: Physician’s or Chiropodist/Podiatrist’s referral required.

OFF THE SHELF ORTHOPAEDIC SHOES AND ORTHOPAEDIC MODIFICATIONSOrthopaedic Shoe (s) or the permanent modification of a regular shoe. Modifications may include sole buildups, lifts, wedges, steel plates, caliper plates, stirrups to accommodate braces and self-adhesive closures. Combined Maximum Benefit $150.00 per benefit period per covered person.Note: Physician’s or Chiropodist/Podiatrist’s referral required. Exclusions: The Orthopaedic Shoe Benefit does not include shoes purchased only to accommodate orthotics or comfortable walking shoes such as Berkenstock, Nike, Brooks, Rockport, etc.

MEDICAL EQUIPMENT/SUPPLIESThe following medical equipment and supplies are covered when prescribed by a physician. Such equipment must be required for therapeutic use. Coverage is for supplies and equipment available on a rental basis, however at the discretion of ClaimSecure we may consider the cost of purchase for the equipment or supply.Pre-approval may be required for specific medical equipment.Note: Provincial assisstive device program maximums will be taken into consideration where applicable.

Breathing Equipment- Continuous Positive Airway Pressure Machine (CPAP)

Maximum Benefit one (1) per lifetime per covered person.Exclusions: Supplies are excluded.

- Intermittent Positive Pressure Breathing Machine (IPPB) Maximum Benefit one (1) per lifetime per covered person.Exclusions: Supplies are excluded.

- Apnea Monitors for respiratory dysrhythmias- Mist Tents and Nebulizers- Oxygen and the equipment needed for it’s administration- Tracheostoma tubes

Orthopaedic Equipment - Braces

Note: Braces are wearable, orthopaedic appliances and must be made of rigid or semi-rigid material such as metal or hard plastic to hold parts of the body of the correct position.Exclusions: Elastic supports and foot orthotics and dental braces are not considered as an orthopaedic appliance.

- Splints: including splints attached to a brace Exclusions: Intra-oral splints are not covered.

- Casts- Cervical Collars

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SECTION B.3

CLIENT #GROUP #

Internal Use Only Prosthetic Equipment

- External Breast Prosthesis Maximum Benefit is one (1) per benefit period per covered person.Note: Required because of a total or radical mastectomy.

- Standard Artificial Limbs Exclusions: Myoelectric limbs.

- Artificial Eyes including repair and replacement- Stump Socks - Shoulder Harnesses

Mobility Aids- Standard Wheelchair, or where medically required electric wheelchairs.

Maximum Benefit of $3000.00 every sixty (60) consecutive months per covered person. Note: Pre-approval required from ClaimSecure.

- Canes- Crutches- Walkers

Other Medical Equipment- Blood Glucose Monitoring Machines

Maximum Benefit is once every forty-eight (48) consecutive months per covered person.

- Insulin Infusion SetsExclusions: Insulin Infusion Pump.

- Intra-uterine Contraceptive DevicesNote: must inserted by a doctor.

- Standard Hospital Beds Exclusions: Electric hospital beds.

- Surgical Brassieres Maximum benefit of two (2) per benefit period per covered person.Note: Following a mastectomy.

- Support Hose and Compression Stockings.Maximum Benefit of four (4) pairs per benefit period per covered person.

- Transcutaneous Nerve Stimulators for the control of chronic pain (Tens machine).Maximum benefit is $700.00 in a person’s lifetime per covered person.

- Wigs Maximum Benefit of $200.00 in a person’s lifetime per covered person.Note: For cancer patients undergoing chemotherapy.

- Bed Rails- Colostomy and Ileostomy Supplies- Custom-Made Burn Garments- Custom-Made Pressure Supports for lymphedema- Head Halters - Traction Apparatus- Trapeze Bars- Urethral Catheters

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SECTION B.3

CLIENT #GROUP #

Internal Use Only

MEDICAL EQUIPMENT/SUPPLIES (con’t)Exclusions: The medical equipment benefit does not include charges for the maintenance of medical equipment rented or purchased. Rental costs may not exceed the purchase price.

DIAGNOSTIC SERVICESDiagnostic laboratory and x-ray procedures which are defined as diagnostic testing of blood, urine or other bodily fluids and tissues and radiographic examinations performed in the covered person’s province of residence are covered when coverage is not available under the provincial government plan.

EYE EXAMSMaximum Benefit is one (1) eye exam per covered person to a maximum of $50 per benefit period Note: Provided by a licensed ophthalmologist or optometrist.

VISION CARE SERVICESFrames and prescription lenses, or prescription contact lenses Maximum Benefit is $200 every twenty-four (24) consecutive months per covered person. Exclusions

Refractions required by a Client, government body or other third party. Safety glasses or safety goggles. Replacement of lost, stolen or broken lenses or frames. Duplicate or spare eye glasses. Intra-ocular lens implants. Non-prescription sunglasses.

SPECIAL VISION BENEFIT AFTER SURGERY An initial pair of frames and one (1) corrective lens, contact lens or prosthetic lens after cataract surgeryMaximum Benefit is one (1) per eye per lifetime per covered person.Note: This benefit is in lieu of the frames and prescription lenses, or prescription contact lenses benefit.

HOSPITAL CAREStandard semi-private room charges provided to a covered person in a public, licensed hospital.Note: The hospital stay must be for acute care as a result of illness, injury and/or pregnancy.Exclusions: Room charges for outpatient care, day surgery, private hospital, nursing home, chronic care facilities, home for the aged, rest home.

CONVALESCENT CAREConvalescent facility room charges provided to a covered person who is receiving active treatment or rehabilitation for a condition that will significantly improve as a result of convalescent care.Maximum Benefit is $20 per day up to one-hundred-twenty (120) days per covered person per disability and immediately follows three (3) or more days of hospital confinement of acute care.

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SECTION B.3

CLIENT #GROUP #

Internal Use OnlyExclusions: Room charges for chronic care, custodial care, home for the aged, alcohol and substance abuse, mental health.

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48

SECTION B.3

CLIENT #GROUP #

Internal Use Only

General Limitations & Exclusions for Extended Health BenefitsIn addition to the limitations and exclusions of this benefit plan, and those limitationsand exclusions contained in the description of the benefits, the Extended Health Benefits do not cover services, supplies or equipment that are primarily intended to facilitate:

expenses that private insurers are not permitted to cover by law

services or supplies the person is entitled to without charge by law or for which a charge is made only because the person has insurance

service and supplies that do not represent reasonable treatment services or supplies associated with: services rendered for cosmetic reasons,

exercise, weight loss, physical fitness or sports, environmental or atmospheric control in the home or workplace

the diagnosis or treatment of infertility services or supplies associated with covered items, unless specifically listed as a

covered expense extra medical supplies that function as spares or alternates services or supplies received outside Canada except as provided under the out-

of-country emergency care services covered by any Workplace Safety and Insurance Board unless prohibited

by any Government legislation services and supplies not shown in the included list of benefits expenses for services, treatment or supplies, which are considered experimental

in nature any claim expense or service provided by an immediate family member are not

eligible for coverage/payment health care services or supplies required as a result of war, terrorism rebellion or

hostilities of any kind, whether or not the covered person is a participant health care services or supplies required as a result of participation in a riot or civil

disturbance health care services or supplies due to intentional self-inflicted injury

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SECTION C.1

CLIENT #GROUP #

Internal Use Only

New Client Access Services

SYSTEM REQUIREMENTSThe information acquired in this document will ensure that you have the requirements to use our systems that will allow ClaimSecure to maintain proper support and ensure maximum performance.

System Contact:


Technical Contact:


SYSTEM INFORMATION ITEM MINIMUM RECOMMENDED ACTUAL

Operating System Windows 9x/NT/ME/2000 Windows 9x/NT/ME/2000/XP

Hardware Pentium II 266Mhz Pentium III or higher

PC System Memory (RAM) 64MB 128MB

Internet Browser Internet Explorer Version 6.0 Internet Explorer 6.01 SP1

SSL 128 bit 128 bit

Adobe Acrobat Reader Acrobat Reader 4.0 Acrobat Reader 5.0

Screen Resolution 800 X 600256 Colours

1024 X 76832 Million Colours

Internet Connection (Minimum 56k) Dedicated Internet Connection

Citrix ALE Web Client(Online Reporting)

Plug-in (32-bit) version 4.21.779

Plug-in (32-bit) version 4.21.779

CLIENT SUPPORTClaimSecure Web Site http://www.claimsecure.com ClaimSecure Online Reporting http://www.claimsecure.com/en/webreports/ ClaimSecure Web Support (e-mail) [email protected] Helpdesk (e-mail) [email protected] Helpdesk Phone 1-705-669-2621

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SECTION C.1

CLIENT #GROUP #

Internal Use Only

WEB APPLICATIONS(Benefits and Eligibility)

CLIENT SECURITY PROFILE

Client Name I.E.: ClaimSecure

Client ID (8 Alphanumeric Characters – no spaces)

Client Logo Please AttachGraphic Size: 205 pixels wide by 56 pixels high, in a

GIF, or JPG format

PRIVILEGES GROUP DIVISIONS UNITSEligibility Entry

Eligibility Query

The following is for TPA USE ONLYPRIVILEGES GROUP DIVISIONS UNITS

Drug Claims Entry

Drug Claims Query

Patient Exceptions

Exception Totals

Dental Claims Entry

Dental Claims Query

EHC Claims Entry

EHC Claims Query

Regular Price Query

Generic Price Query

Note: TPA Use only – these functions are utilized by our Insurer and TPA (Third Party Administration) clientele. Some Unions, Associations and/or Trustees may also perform claims submission, patient exceptions and price query using these internet applications.

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SECTION C.1

CLIENT #GROUP #

Internal Use Only

WEB APPLICATION USERS

Full Name I.E.: (Jane Smith)

Admin. ID I.E.: (jsmith) (Max 8 Alphanumeric Characters )

Privileges (type any relevant information)


User ID I.E.: (jsmith) (Max 8 Alphanumeric Characters )

















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SECTION C.1

CLIENT #GROUP #

Internal Use Only

ONLINE REPORTING


Client ID (8 Characters – no spaces)

Client Number

Group Number Only required if there are groups to be excluded from the insurance company.

PRINTER CONFIGURATION

Printer Make HP, Canon, Lexmark, Etc

Printer Name Exactly as shown in Printer Folder

ENGLISH FRENCHEnhanced Dental Evolués Dentaires

Enhanced Drug Evolués Médicaments

Standard All Benefits Indemnités des soins de la santé étendues

Standard Dental Soins Dentaires

Standard Drug Soins Médicaments

Standard EHB

CLIENT DOWNLOADS (Claims Extracts)


Client ID (8 Characters – no spaces)

Client Number

Group Number Only required if there are groups to be excluded from the insurance company.

Download Options

Drug Dental EHB

Other Specify:

E-mail Destination: [email protected]

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SECTION C.1

CLIENT #GROUP #

Internal Use Only

INTERNET BROWSERThis site has been designed to view optimally with Microsoft's Internet Explorer web browser, version 6.0 or later. This is, however, just the recommended configuration and every effort has been made to ensure the pages will view properly under earlier versions of Microsoft's Internet Explorer. Additional support may be required for 100% compatibility with other browsers other than Internet Explorer 6.0. Support of any web browser below version 5.x is currently limited to the marketing areas of the ClaimSecure web site.

The top web browsing software from Microsoft is free, so ensure you are using the latest technologies by visiting their web site.


SSL (Secure Socket Layer)Browser support for 128 bit Secure Socket Layer is required to support encrypted data streams between the client and web server.

SCREEN RESOLUTIONClaimSecure.com is designed to be optimally viewed at a minimum screen resolution of 800 x 600. You may need to check your computer's resolution settings for best viewing. Horizontal scrolling may occur if viewed at a lower resolution.

HARDWAREA Pentium III 733Mhz or higher running Windows 9x/NT/ME/2000/XP is recommended in order to support the required web browser and applications at the required screen resolution. Any computer running the required software will be adequate but performance may suffer as a result of using a slower system.

JAVASCRIPT AND COOKIESTo benefit from the full functionality on the web site, JavaScript must be enabled in your browser. Corporate clients should also configure their firewall and the proxy server on their network so as to support JavaScript and Java applications.A "cookie" is a piece of data that is sent to your browser from a web server and stored by your browser on the hard drive of your computer. Your browser settings must be set to accept cookies before you can use www.claimsecure.com . Most browsers by default are set to accept cookies, but you can change your browser settings to refuse them.ClaimSecure.com does not use cookies to retrieve personal information about you from your computer. Additionally, you will experience problems if your browser has cookies disabled.You can ensure that JavaScript and Cookies are enabled on your browser by following the instructions for your browser:

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http://www.claimsecure.com/


SECTION C.1

CLIENT #GROUP #

Internal Use Only

FORMS LIBRARYDue to the several different platforms in word processing software available, we are providing all our downloadable documents in the PDF (Portable Document File) format. To make use of these documents, please ensure that you have downloaded and installed the (free) Adobe Acrobat Reader software. Click the icon below to go to Adobe's web site.

To download a PDF, you can do either of the following:

1) Click a link to a PDF in your web browser. This will load the Adobe Acrobat plug-in/viewer software and display the PDF document within the web browser window. Use the save control button on the Adobe Acrobat Reader toolbar to save the open PDF document.

[OR]2) Right-Click any link to a PDF document, and choose the "Save Target As" option from the context menu

that appears.


ON-LINE REPORTINGTo access ClaimSecure web reports via the Citrix Metaframe connection, you must have

the CitrixMetaframe client software installed. To obtain this software for your browser, you may

downloadthe ICA client software and installation instructions from the Citrix web site.

ICA 32-bit Windows Web Plug-In Client for Web Browsers (recommended)http://download2.citrix.com/FILES/en/products/client/ale/current/

wfplug32.exe

FIREWALL INFONetwork Administrators please ensure that the following ports are enabled to access the On Line Reporting Application.

1494 TCP1604 UDP

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SECTION C.2

CLIENT #GROUP #

Internal Use Only

Existing User Access Services

Client Service Rep Received Date 01/01/2003Effective Date 01/01/2003

Web Support Section

WEB APPLICATIONS(Benefits and Eligibility)

Client/Broker/TPA Name

Client ID


GROUP DIVISIONS UNITS

Systems Request Section

ONLINE REPORTING


Client Number

Group Number

CLIENT DOWNLOADS(Claim Extracts)


Client Number

Group Number

Drug Dental EHB

Other Specify:

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SECTION C.2

CLIENT #GROUP #

Internal Use Only

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57

SECTION D

CLIENT #GROUP #

Internal Use Only

Schedule Of Fees

In consideration for the services to be provided by ClaimSecure, (Insert The Name Of The Payor) (“the Payor”) shall pay to ClaimSecure the fees (“the Fees”) set out below: at the times and in the manner provided for in Section E.

Fee Period From: , 20 to , 20

SERVICES FEE AND ADDITIONAL CHARGES(where applicable)

CLAIMS PROCESSINGDrug claims processing for a EDI claim

for a Paper claimDental claims processing for a EDI claim

for a Paper claimExtended Health claims processing

Hospital Major Medical Vision

for a claim for a claim for a claim

HSSACost Plus

for a claim for a claim

STOP LOSSStoploss % of Paid ClaimsPLAN ADMINISTRATIONTPA fees % of Billed PremiumReporting:

Standard Reports Included Enhanced Reports Initial $950, $550 additional Customized Report Fee for Service Basis

Clinical Services : Formulary Management Special Authorization Employee Health Education

for a EDI claim$ / reviewFee for Service Basis

Audit Fee for Service Basis

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SECTION D

CLIENT #GROUP #

Internal Use Only








HSSACost Plus







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SECTION D

CLIENT #GROUP #

Internal Use Only








HSSACost Plus







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SECTION D

CLIENT #GROUP #

Internal Use Only

In addition to the Fees, the Payor shall be liable to pay to ClaimSecure the dollar value all claims costs that are approved for payment by ClaimSecure in accordance with the Benefit Plan.

ClaimSecure currently issues claims invoices twice per month. Invoice payments are due based on the payment schedule used to calculate the deposit requirements (see Section E).

In the event that the Payor fails to pay any invoice when due, ClaimSecure may, without additional notice, utilize the Deposit Amount in Section E and immediately cease providing any other ClaimSecure Service until payment has been received and the Deposit Amount has been replenished as required.

For purposes of the above Fee Schedule: “Paid Claims” means the total number or dollar value (as applicable) of claims paid by

ClaimSecure on behalf of the contracted party to healthcare providers or to plan members and their dependants;

“Submitted Claims” means, the total number or dollar value (as applicable) of claims submitted to ClaimSecure by to healthcare providers or to plan members and their dependants.

the Payor acknowledges that the Fees are exclusive of any applicable Goods and Services Tax or other federal, provincial, municipal or other taxes which now or in the future may apply to the Fees, to the Claims, or to the services provided by ClaimSecure and that the Payor shall be responsible for their payment of such applicable taxes in addition to the Fees.

Subsequent to the expiry of the latest of the Fee Periods set out above, ClaimSecure may change the Fees charged pursuant to this Agreement on providing the Contracted Party with 60 days’ prior written notice of the details of such change; and such change will take effect on the first day of the month following the end of the 60 day notice period.

Charges for services not identified in the Fee Schedule above will be quoted upon request.

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SECTION E

CLIENT #GROUP #

Internal Use Only

Deposits

The Payor agrees to pay ClaimSecure the amounts outlined in this Section E contemporaneously with the execution and delivery of this Agreement to be credited to the Payor. The payments may include an amount in respect of costs incurred but not reported ("IBNR") and an amount for Provider Costs (the "Provider Payment Amount") (the IBNR and Provider Payment Amount are hereinafter collectively referred to as the "Pre-Payment Amounts"). The IBNR may be posted by the [contracted party] to the credit of ClaimSecure by way of a certified cheque payable to ClaimSecure or an irrevocable standby letter of credit on terms satisfactory to ClaimSecure with a financial institution acceptable to ClaimSecure. The Provider Payment Amount must be paid to ClaimSecure by certified cheque. The calculation of the Pre-Payment Amount is based on the number of Employees and ClaimSecure’s assessment of the required amount for Provider Costs. On the first anniversary date of this Agreement, the amount of the Pre-Payment Amount may be recalculated based on the actual Claims experience.

1. DEPOSIT TYPE: Straight ASO (IBNR) Budgeted ASO (if yes, complete # 2)

2. BUDGETED ASO AUTHORIZED BANK DEDUCTIONS: Bank Name: Bank Address:

Bank Telephone Number Bank Contact: Bank Account Number: Bank Transit Number: Bank Number: 3. DEPOSIT REQUIREMENT: $ 4. INVOICING INFORMATION:a) Primary Invoice Client Consultant/Broker/TPAName Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Contact Title Contact E-mail Address b) Client Tax Status Taxable Exempt

PST Premium Tax GST

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SECTION E

CLIENT #GROUP #

Internal Use Only

Attach proof of exemption from tax where applicablec) Separate Invoices (Additional Fee Applies)

Is a separate invoice required (for mailing to one or more Divisional/Unit Addresses)Yes No If Yes, please provide details below:

Name Street Unit/Suite City Province/State Postal/ZIP Code Country Telephone Fax Contact Title Contact E-mail Address

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SECTION E

CLIENT #GROUP #

Internal Use Only

Drug Dental Hospital Vision Major

MedicalNumber of Cardholders Claim Deposit – Mandatory Average Claim Cost $ 43.00 $ 141.00 $ 150.00 $ 150.00 $ 85.00Admin Fee % 14.00 % 14.00 % 14.00 % 14.00 % 14.00 %Taxes (10% value-Ont & Que Companies only)

$ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00

Utilization 92.50 % 39.00 % 1.00 % 11.00 % 11.00 %Average Claim $ per member per month

$ 45.34 $ 62.69 $ 1.71 $ 18.81 $ 10.66

Projected Annual Claims per member

$ 544.12 $ 752.26 $ 20.52 $ 225.72 $ 127.91

Project Annual Claims – Entire Group

$ 26,661.98 $ 36,860.90 $ 1,005.48 $ 11,060.28 $ 6,267.49

Lagg Factor % 4.17 % 4.17 % 4.17 % 4.17 % 4.17 %Claim Deposit $ 1,111.80 $ 1,537.10 $ 41.93 $ 461.21 $ 261.35

Payable by cheque onlyTotal Claim Deposit $ 3,413.40

Extended Payment Terms Deposit3 Days15 Days30 Days45 Days $ 1,111.80Extended Payment Terms Deposit $ 0.00 $ 0.00 $ 0.00 $ 0.00

Payable by cheque onlyTotal Extended Payment Terms Deposit $ 0.00

(Note: This deposit is not applicable if payment is made by EFT or sent via courier within 0 – 3 days from invoice date.)

Total Claim Deposit $ 3,413.40Total Extended Payment Terms Deposit $ 0.00TOTAL DEPOSIT REQUIRED $ 3,564.42

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SECTION E

CLIENT #GROUP #

Internal Use Only

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SECTION F

CLIENT #GROUP #

Internal Use Only

Declarations and Signatures

The Contracted Party and the Payor (if a different party) hereby declare(s) that, to the best of their knowledge, the statements and answers contained above are full, complete and true as of the date hereof and agrees that:

1. Such statements and answers shall constitute the Application for and form part of the Contract;

2. The Contract will not become effective until this Application has been approved by ClaimSecure;

3. This Agreement and the ClaimSecure Services to be provided pursuant to this Agreement do not constitute a contract for insurance or risk loss, and ClaimSecure is not acting as an insurer or indemnifier for any such benefits and services; and

4. The parties hereto acknowledge that: the implementation of the Benefit Plan and the Master Application may require

interpretation and, in some cases, may be subject to more than one interpretation;

ClaimSecure has the authority to interpret the provisions of the Benefit Plan and the Master Application; and

any interpretation adopted by ClaimSecure in good faith and in a reasonable manner is binding.

Any delay or failure by either party hereto in performance hereunder shall be excused if and only to the extent that such delays or failures are caused by occurrences beyond such party's control, including acts of God, decrees or restraints of governments, strikes or other labour disturbances, war, sabotage, and any other cause or causes, whether similar or dissimilar to those already specified, which cannot be controlled by such party; provided that the party seeking to excuse its performance shall promptly notify the other party of the cause therefor, such performance shall be so excused during the inability of the party to perform but for no longer period, and the cause thereof shall be remedied so far as possible with all reasonable dispatch.

Except as otherwise expressly provided herein, any dispute, difference or question arising between the parties concerning the construction, meaning, effect or implementation of this Agreement or any part hereof will be settled by a single arbitrator mutually agreed on by the parties or failing agreement, an arbitrator appointed pursuant to the Arbitration’s Act (Ontario).

From time to time ClaimSecure and the Contracted Party will at their own expense, execute and deliver such additional documents and other assurances as may be reasonably required to carry out the intent of this Agreement.

Except as specifically provided herein, no party may assign any of its rights or benefits under this Agreement to any person without the prior written consent of the other party or parties hereto.

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SECTION F

CLIENT #GROUP #

Internal Use Only

If there occurs any Change in Law which materially alters the rights or obligations of either party under this Agreement, the parties shall equitably adjust the terms of this Agreement to take into account such Change in Law. If the parties are unable to agree upon an equitable adjustment within sixty (60) days after either party notifies the other of such a Change in Law, this Agreement shall terminate.

Dated at [ Location ] this [ date ] day of [ Month ] , [ year ] .

Contracted Party

Per: Authorized Signatory


Payor



ClaimSecure Inc.



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Documents

New Client Contract - ClaimSecure Inc.claimsecure.com/content/forms/secureadvisor/master_application… · Web viewLevel 1 services include Diagnostic, Preventive, Minor Restorative,