Read Microsoft Word - 6701 R1 OxFlex ACH PreFund rel 1.11.05.doc text version

OxfordFlexSM Pre-Funding, Payroll Contribution and Manual Claims ACH Authorization Release (For Employers requesting Oxford Benefit Management to maintain Bank Account)

Attn: OxfordFlex Claims Department, P.O. Box 1021, Eatontown, NJ 07724; Phone: 800-790-3249; Fax: 732-676-2659

AGREEMENT FOR PRE-AUTHORIZATION DEBITS AND CREDITS FOR EMPLOYEE CONTRIBUTION FUNDING & DISBURSEMENTS VIA AUTOMATED CLEARING HOUSE (ACH)

, the Group, and Oxford Benefit Management Inc. ("OBM") entered into agreements which provides flexible spending benefits for the Group's covered employees and their eligible dependents. Group Information Group Name Contact Person Phone Number ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ___________________________ Fax Number ____________________

To pay the Plan benefits, the Group authorizes OBM to initiate variable electronic debit and credit entries via ACH to the Group's bank account indicated below, and authorizes the below named depository to debit and credit the same to such account, via ACH. Bank Information Depository Name City Transit/ABA No. State Branch Zip Bank Account No.

Please check those that apply: Pre-funding of OxfordFlex Healthcare Contributions via ACH Under the ACH arrangement, __________________________ will provide a pre-fund amount of annual health contributions (25% if debit card is offered; 4% otherwise). You will receive a general notification via fax that indicates the total amount of pre-fund . Subsequent to the fax notification, your account will be "swept" for the amount indicated on the general notification. On the same day that the fax is sent, a subsequent detailed notice equivalent to the amount of the general notification will be mailed to your attention. Funding of Employee Contributions via ACH (Employer sends contributions to Oxford Benefit Management Under the ACH arrangement, __________________________ will provide employee contributions to OBM on a frequency indicated on the employer group application. You will provide a payroll report reflecting deductions and OBM will review for any discrepancies. You will receive a general contribution notification via fax that indicates the total amount of expected pay period contributions. Subsequent to the fax notification, your account will be "swept" for the amount indicated on the general notification. On the same day that the fax is sent, a subsequent detailed contributions listing equivalent to the amount of the general notification will be mailed to your attention.

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Weekly Minimum Balance Maintenance and Additional Funding for OxfordFlex Healthcare Claims Payment Under the ACH arrangement, __________________________ will receive a notification via fax that indicates the total amount of funds required to maintain the required minimum balance of OxfordFlex Healthcare contributions (15% for employer groups offering the debit card). Additionally, you may receive notification for funds required to pay for OxfordFlex Healthcare claims in excess of amounts contributed to date. Subsequent to the fax notification, your account will be "swept" for the amount indicated on the general notification. On the same day that the fax is sent, a subsequent detailed contributions listing equivalent to the amount of the general notification will be mailed to your attention. The employer, not Oxford Benefit Management (OBM), shall remain the group's fiduciary for the group's health benefit plan. The employer group agrees to fund claims for all eligible expenses permitted for qualified cafeteria plans pursuant to Section 125 of the Internal Revenue Code as well as Transit and Parking Accounts. The employer group also agrees to impose proper collection procedures to collect monies for claims submitted by employees for expenses which are not eligible for reimbursement under a qualified cafeteria plan or Transit and Parking Account. Authorized Signature Group Date ___________________________________________

Note: OxfordFlex employer groups and members may want to consult a tax advisor regarding Section 125 qualified cafeteria plans and other reimbursement accounts permitted by the Internal Revenue Code.

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