Operations

1. Operations Nanjing Operations

2. HR & Admin. Corp. Service China Organization Structure Executive Office IT Dept. Audit/ Quality Compliance Process Team 1 Process Team 2 Outsourcing Unit Support Support Team 1 Team 3 Claims Processing Claims Processing Team 2 Team 4 Group Administration Group Administration

3. Life of a Claim OCR Mail Room OCR Vendor Support Unit Claims Dept. US China China US NON-OCR Mail Room Support Unit Claims Dept. Support Unit Check/EOB Printing

4. Support Unit: Functions & Flow US China Vendors Claims Dept. Support Unit Houston Fix Errors (Panther) Preprocessing (WLT) OCR ƒ ‚  Adjudication Mail Repricing: internal & external (requires tracking) „ Data Entry Preprocessing Sort Mail Member Search Correspondence Processing Filing External Repricing Member Identification Duplicate Check Reprice Verfication Provider Identification Batch/Claim Reconciliation: 1. Mail Room – OCR Vendor 3. Panther - WLT 2. OCR Vendor – Panther 4. WLT - Website

5. Claims Unit: Adjudication Flowchart De-Dup Not Dup Dup Clarification, itemized bill need to be obtained Patient Eligible? Active? OI, FTS No ICD-9 (Diagnosis Code) Deny/ Inquiry further Yes Pre-x; Accident; Plan exclusion? Cost Containment Non-P Negotiation HBA CPT (Procedure Code) Plan Exclusion? Yes Coverage Code RX order? UM Pre-cert EOB/Check generated

6. Claims Unit: Correspondence/Call tracker/E-mail • Additional info received • OI, FTS, Injury Details, etc. • Payment Dispute • Either from Provider or member • Check Status Tracer • Claims Status look-up • Eligibility • Benefits inquiries • Identify Problems • Further Research • Confirm Re-pricing • Update processing system • Process/ re-process • Re-issue checks • Referred to other desk • Form type of reply

7. Group Administration: Functions

8. Automatically Process Card Program Initial COBRA Notice Welcome Letter Including Web Login New Enrollment Eligibility Change Termination Web Process Special Card Request ID Card New Enrollment Package ID Card Online Finalization Online Finalization Online Finalization COBRA Election Notice Access Program COBRA Participant Member Move Change in WLT Upon receipt of COBRA Premium, update eligibility Record in WLT. GA: Member Maintenance & Administration WLT

9. WLT Remit premium or commission. Premium Billing Web Upon receipt of premium payment, update WLT. PPO, UM Vendors, S/L Carrier & Broker etc. Claim Analysis Report Stop Loss Reporting & Filing Customized Report Client Reporting System & Administration

10. Process Re-Engineering • We constantly strive to find innovative methods for re-engineering the claims administration process to improve the effectiveness and scalability of our operations. • These changes we have made in breaking down the claims process enable us to: • Have better performance measures and control • Operate with a higher degree of specialization • Decrease training time • Reduce reliance on any one individual • Enables us to move closer to a variable unit cost production structure (contractor)

11. Focus on Productivity & Quality Maximizing productivity is one of our top operational priorities. This goal is emphasized during all process design discussions and is evident in our efforts to continuously measure, manage, and improve the productivity, efficiency, and effectiveness of our various teams. • To ensure our quality standards consistently meet and exceed our quality goals, we have implemented a number of internal quality assurance procedures. • Random audits and cross-checking • Meetings with client service teams • Supervisory & management reviews • Monthly seminars on “Errors & Risks” and regular training

12. Management Control • Our management, operational, and client reporting enables our business and client service teams to enhance customer satisfaction. • Daily reports: production, productivity, & status • QC reports • Bi-monthly reports: paid claims; inventory; claims exceeding $5,000; cases with pre-certification; cases in large case management • Aggregate reports (claim $ amount by group) • These various reports offer important analytical insight which allows us to: 1) measure & optimize our operations and 2) take proactive steps to increase client satisfaction.

13. HIPAA & Regulatory Issues • Health Insurance Portability • We request Creditable Coverage Certificate for every eligible participant • Privacy & Security • System security: users are assigned system logins & passwords with appropriate security levels • Physical security: security codes changed regularly and visitors not allowed in processing areas • Documents containing PHI are kept within the operations department • Claims and correspondence containing PHI are shredded prior to disposal • EDI • We are able to receive claims via EDI

14. Recruitment and Training GENERAL We recognize that our employees are our most important asset. Hence, we screen new applicants carefully, conducting multiple rounds of in-depth interviews and reference checks. We review each employee’s performance regularly and build leadership from within. Our “pay for performance” compensation structure and benefit packages are competitive and will enable us to retain our valuable members.

15. Hiring Strategy • We hire people who: • Have good command of English • Have solid work ethic • Work well in a team environment and can work with a diverse group of people • Exhibit a track record of striving for excellence • Understand the importance of responsibility and ownership of work • Have initiative and leadership potential • For recruiting, we: • Review résumés, educational background, accomplishments, and work experience • Conduct multiple rounds of in-person interviews • Give candidates an English comprehension & typing test

16. Salaries and Benefits • In determining salaries we: • Examine each situation on an individual basis • Adhere to a performance grading system and tie pay to performance • Strive to create benchmarks which are perceived as fair and consistent for comparable positions throughout the firm • Offer competitive compensation packages relative to the market in our area • Our benefits packages include: • Pension Benefits • Medical, Unemployment, and Worker’s Compensation Insurance • Discretionary Bonus • Paid Holidays & Vacations

17. Training • The HR Department is responsible for training and development of training materials; however, all team members play a role in the training process. • There are two primary phases for the Claims Examiner training: • Foundational Training Sessions • B. Claim Adjudication Exercise Sessions

18. Training • A. Foundational Training Sessions: • 3 days “Overview of Health Insurance”: terms, definitions, codes… followed by a comprehension test. • 2 days “Identification of Claims Forms”: • HCFA–1500, UB92, Dental Claim Form, EOB. • 2 days “Plan Overview”: deductible, limits, benefits, covered charges, and exclusions. • 7 days “Systems Training”, “8 Steps of Claim Adjudication”…. followed by a comprehension test.

19. Training • Eight Steps of Claim Adjudication: • 1) Claim form 2) Plan 3) Eligibility 4) Dates • Charges 6) Deductible 7) Coinsurance 8) Benefits • B. Claim adjudication exercise sessions: • The duration of the exercise phase lasts approximately 3 to 5 weeks, depending on the trainee’s comprehension of claim procedures. During this phase, the trainer will do the following:

20. Training • Select less complicated or low dollar amount claims for trainees to adjudicate. Most often, these types of claims would be dental claims, pharmacy bills, or claims under $100. • Constant monitoring of progress • Quality control (100% audit) • Group discussion on common problems & important considerations • Ongoing performance reviews • After the exercise phase is successfully concluded, the trainee will be assigned junior examiner functions by their team leader.

21. Continuous Cross Training System • We have developed and implemented a continuous cross-training system where all team members serve as both trainers and trainees. We employ this system in our effort to: • Provide an opportunity for professional growth to all our employees consistent with our message of rewarding value and building moral • Foster sharing of information and encourage continual development to free up time for increasingly more value-add responsibilities • Establish a natural filter system to identify leadership • Create a scalable training platform to support expansion • Employees are rewarded for successfully managing the delegation of responsibilities and for raising the levels of their peers.

22. Training Materials • Foundational Training Materials: • Claim Adjudication Overview • Medical Processor Training Aids • Advanced Training Materials: • Claims Administration Handbook

23. Training Schedule

24. Acquisition and Transition • To ensure a successful acquisition transition, we have a systematic procedure for planning and implementing the transition process. • Analysis • Volumes based on historical volumes • Complexity of SPDs • Plan set-up integrity and questions • System analysis • Current operational structure • Identify areas for improvement • Planning • Staffing plan (reduction phases and resources needed) • Operational planning to establish timeline and task list • IT/ Systems planning

25. Acquisition and Transition • Implementation • Execute on operational transition plan • Improve processes as we centralize operations

26. Acquisition and Implementation • Implementation Items • Transfer of important records and information • Send out initial COBRA notices & new ID cards • Carry out client communication plan and establish weekly client conference calls • Notify appropriate third-party vendors (i.e. PPO, UR, PBM, MGU, and clearinghouse vendors) • Execute Business Associate Agreement with outside vendors • Request data file format from vendors • Request Certificate of Creditable Coverage from clients

27. Claims System Experience • GBAS • LuminX • HSP • RIMS • WLT • CAPS/2020 • Eldorado • ClaimFacts • Genelco • Facets

28. Executive Office HR & Admin. IT Dept. Director Operations Audit/ Quality Compliance Corp. Service Process Team 1 Process Team 2 Process Team 3 Outsourcing Unit Expansion Modules