<COMPANY LETTERHEAD>
Humana Renewal Underwriting:
This form can be utilized to request certain claims information due to Texas HB2015.
Company Representative Submitting Report Request / Agent of Record:Name:
Position:
Company Representative Signature:
Phone number to call with report clarification / questions:
Per House Bill 2015 as a certified plan sponsor (see above), I am requesting the following reports and options (as indicated by checks to the corresponding boxes):
Amendment and Certification Forms
Per Federal HIPAA regulations, this authorization for release of information is required for groups with less than 10 members. For groups with less than 10 members, this form must be completed before any reports will be released.
Premium vs. Claims Report (up to a maximum of 36 months of data)
Dates requesting: From to
Report contains:
• Paid claims experience by month, including claims experience for medical, dental and pharmacy
• Total premium paid by month
• Total number of covered employees on a monthly basis by coverage tiers.
Pending Claims Report
Large Claims Report (12 month period before date of the report)
(available on paid claims exceeding $15,000)
Pre Certification Report
A statement describing pre-certification requests for hospital stays of 5 days or longer that were made during the 30-day period preceding the date of the report (production)
Prognosis Report
After review of the initial reports above, the group may subsequently request additional information on individuals whose claims exceed $15,000. This report must be requested separately from the reports above.
A signed Amendment and Certification form is required for release of this report regardless of the number of members.