LLM_Engineering_OLD/week5/knowledge-base/contracts/Contract with WellCare Insurance Co. for Healthllm.md

Contract with WellCare Insurance Co. for Healthllm

Contract Date: March 8, 2025 Contract Number: HL-2025-0021 Parties:

• Insurellm, Inc.
• WellCare Insurance Co.

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Terms

1. Coverage: Insurellm agrees to provide WellCare Insurance Co. with access to the Healthllm platform, enabling comprehensive health insurance operations including plan design, eligibility verification, claims adjudication, and member engagement.

2. Duration: This agreement is effective for a period of 12 months from the contract date, with automatic renewal unless terminated with 30-day written notice.

3. Payment: WellCare Insurance Co. shall pay a monthly fee of $8,000, due by the 1st of every month for the Essential Tier package.

4. Member Coverage: Essential Tier supports health insurance administration for up to 15,000 covered members. Current enrollment: 11,000 members.

5. Confidentiality: Both parties agree to maintain strict confidentiality of proprietary information, protected health information (PHI), and member data in compliance with HIPAA regulations.

6. HIPAA Compliance: Insurellm operates as a Business Associate and maintains full HIPAA compliance including Business Associate Agreement (BAA).

7. Liability: Insurellm's liability is limited to direct damages not exceeding the total fees paid in the preceding 12 months.

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Renewal

Unless either party provides written notice of termination at least 30 days prior to contract expiration, this agreement automatically renews for successive 12-month terms. Pricing may be adjusted annually with 60 days' advance notice, capped at 10% increase per year.

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Features

WellCare Insurance Co. will receive the following Essential Tier features:

1. Intelligent Plan Design: AI-powered tools for creating competitive health plans:

   • Market trend analysis and competitive benchmarking
   • Member demographic analysis
   • Healthcare utilization pattern analysis
   • Benefit structure optimization
   • Deductible and copay modeling
   • Network configuration recommendations

2. Real-Time Eligibility Verification: Instant coverage verification:

   • Provider network integration for real-time checking
   • Member status validation
   • Coverage level confirmation
   • Dependent eligibility verification
   • Prior authorization status
   • Reduces claim denials due to eligibility issues

3. AI-Driven Claims Adjudication: Automated claims processing:

   • Machine learning-based claims review
   • Fraud detection and prevention
   • Payment accuracy verification
   • Auto-adjudication for clean claims
   • Denial management and appeals tracking
   • Learning from historical claim patterns

4. Provider Network Management: Comprehensive network administration:

   • Provider contract management
   • Credentialing and re-credentialing workflows
   • Network adequacy monitoring
   • Provider performance metrics
   • Contract negotiation analytics
   • Cost savings opportunity identification

5. Member Engagement Platform: Mobile-first member portal:

   • Digital ID cards
   • Claims status tracking
   • Provider directory search
   • Coverage information access
   • Telehealth service integration
   • Push notifications for preventive care

6. Basic Medication Management:

   • Formulary management tools
   • Prior authorization workflows
   • Generic substitution recommendations
   • Drug interaction checking
   • Medication adherence tracking

7. Regulatory Compliance Engine:

   • ACA (Affordable Care Act) compliance monitoring
   • State mandate tracking
   • HIPAA privacy and security compliance
   • Automated regulatory reporting
   • Form filing and approval tracking

8. Standard Analytics: Dashboards tracking:

   • Claims volume and processing time
   • Medical loss ratio (MLR)
   • Member satisfaction scores
   • Provider network utilization
   • Cost per member per month (PMPM)

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Support

Insurellm commits to providing comprehensive support to WellCare Insurance Co.:

1. Onboarding: 4-week implementation program including:

   • System configuration for WellCare's plan designs
   • Training for up to 15 staff members (30 hours total)
   • Integration with existing systems (policy admin, provider network)
   • Data migration for current 11,000 members
   • Provider network data import and validation

2. Technical Support:

   • Email and phone support Monday-Friday 7 AM - 7 PM EST
   • Response time: 8 hours for critical issues, 24 hours for standard
   • Online ticketing system with status tracking
   • Knowledge base and FAQ library
   • Video tutorials and user guides

3. Platform Updates:

   • Quarterly feature releases with new capabilities
   • Monthly security patches and bug fixes
   • Regulatory compliance updates as laws change
   • Release notes and upgrade documentation
   • Advance notice of updates (minimum 21 days)

4. Account Management:

   • Named customer success manager
   • Quarterly business review meetings
   • Usage analytics and optimization recommendations
   • Industry trends and best practices sharing
   • Assistance with tier upgrade evaluation

5. Compliance Support:

   • Annual HIPAA compliance review
   • Regulatory update notifications
   • State insurance department filing assistance
   • ACA reporting support (1095 forms)
   • Audit preparation assistance

6. Integration Support: Technical assistance connecting Healthllm with:

   • Existing policy administration systems
   • Provider credentialing systems
   • Pharmacy benefit managers (PBMs)
   • Clearinghouses for EDI transactions
   • Member portal and mobile apps

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Signatures:

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Sarah Chen Title: Vice President of Sales Insurellm, Inc. Date: March 8, 2025

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Dr. Raymond Foster Title: Chief Medical Officer & COO WellCare Insurance Co. Date: March 8, 2025

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This agreement enables WellCare Insurance Co. to modernize their health insurance operations with AI-powered technology while ensuring regulatory compliance and improved member outcomes.