MEDICAL RISK MANAGERS

STOP LOSS CLAIMS ADMINISTRATION GUIDE

TABLE OF CONTENTS

Introduction

Address for Claim Submissions

Contact

Forms

Specific Claims

  • General Conditions
  • Large Claim Notification
  • Specific Claim Submission Requirements
  • Advanced Funding
  • Hospital Bill Audits
  • Subrogation
  • Extra-Contractual Benefits

Aggregate Claims

  • General Conditions
  • Aggregate Loss Notification
  • Monthly Aggregate Benefit Options
  • Aggregate Claim Submission Requirements
  • Aggregate Claim Review – Desk Audit
  • Aggregate Claim Review – On-Site Audit

Reimbursements

Appendix: Electronic Claim Submissions

Appendix: Catastrophic Conditions by Diagnosis

INTRODUCTION

This document should be used as a guide for Stop (Excess) Loss Claim submissions. Each claim will be reviewed independently. Reimbursement will be based on the claim documentation received and/or requested as it relates to the Plan and Stop-Loss Policy provisions.

ADDRESS FOR CLAIM SUBMISSIONS

Claims Department

Medical Risk Managers, Inc.

1170 Ellington Road

South Windsor, CT 06074

Ph: 860-732-3248 Fax: 860-282-4019

Via Email:

CONTACTS

General Questions

Donna Carter

Claims Manager

860-291-3083

Claim Status

Amy Lugo

Senior Auditor

860-291-3084

FORMS

Please use the following Excel forms to submit your claim reimbursement request (double-click the icon to open the embedded form.)

Specific Claim and Notification Form:

Aggregate Claim Form:

Bank Wire Instructions:

SPECIFIC CLAIMS

GENERAL CONDITIONS

Only payments made within the contract period and in accordance with the approved Employee Benefit Plan are reimbursable. Claims shall be deemed paid on the date that the payer directly tenders payment.

As you receive additional claim information, please continue to update the estimate of total cost in order for our reserves to be as accurate as possible.

Medical Risk Managers must be notified prior to the expiration of the contract of any claim that is being investigated or is pending for final benefit determination. If written notice is received, reviewed and approved prior to the expiration of the contract, consideration of this claim normally will be given. We reserve the right to disallow any claim that is not properly and contractually paid within the terms of the contract.

If this contract should terminate or expire, we shall not be liable for Specific Benefits concerning expenses paid after the termination date of the expiration date of the contract, whichever occurs first.

In no event will the Specific Benefit with regard to any covered person exceed the maximum benefit shown in the application/schedule.

LARGE CLAIM NOTIFICATION

We are required to provide notification of potentially large claims to the Stop Loss Carrier and Risk Bearers on a monthly basis. Please use the Specific Excess Loss Claim and Notification Form to provide us with a large claim notification when the following occurs:

  • When you are notified of a pre-certification or receive a potential large claim, please refer to the Appendix containing a list of Catastrophic Conditions by Diagnosis.
  • When you are notified of a potential transplant recipient.
  • When a claim reaches 50% of the Specific Deductible level.

SPECIFIC CLAIM SUBMISSION REQUIREMENTS

Once a claim has exceeded the Specific Deductible, a request for reimbursement should be submitted to Medical Risk Managers using the Specific Excess Loss Claim and Notification Form. Please indicate if you are requesting advance funding. Claim submission requests should include the following documentation:

Employee Enrollment Form:Please provide a copy of the original signed and dated enrollment card. This document should indicate date of hire, original effective date of coverage, termination date, and current work status. A copy of the payroll record may be requested.

COBRA Election Form:If coverage has been cancelled, please provide the COBRA Election form and proof that COBRA premium payments have been paid to date.

Explanation of Benefits or Individual Payment Report:This report must include the First and Last name of the claimant, date(s) of service, provider name, diagnosis, procedure code, received and paid date, total charges, discounted and/or allowable charges, deductible and co-insurance. A copy of the claim check/draft/wire must be submitted if details are not provided in the Explanation of Benefits. Detailed itemization must be included for hospital claims in excess of $50,000.

Proof of Deductible and Coinsurance:If a plan has a deductible or co-insurance amount which needs to be met each calendar or benefit year, we require proof that these amounts were met. If not, we will withhold the outstanding amount until we receive proof.

Large Case Management Reports:If case management has been implemented we will require a copy of the report. This document gives the auditor a review of the claimant condition. It may also give details of the treatment plan and future estimated cost

UB-92 and HCFA Forms: Copies of the physician and hospital bills

Pre-Certification forms: This form verifies that the in-patient confinement dates were authorized. It also includes the length of stay versus approved days. We will request a copy of the pre-certification form for each hospital confinement. If authorization was not given, we will pend the amount of the penalty until we receive a copy of the authorization.

Accident/Police Reports:For all accidental claims, we will need a copy of the police report and/or details of the accident. We also require a copy of the signed subrogation agreement, if applicable

For investigational purposes the following may be required:

COB Forms

Pre-existing Condition Info

Worker’s Compensation Forms

Employee Claim Form

Medicare Election Form

Divorce, Separation, or Court Decree papers

Eligibility Questionnaire

Full Time Student Status

Subrogation Forms

Additionally, please submit copies of all documentation that had an effect on consideration and payment of the claim (for example: copies of medical records and operative reports.

Claim form(s) and documentation can be emailed, mailed, or faxed to the address provided at the beginning of this document.

We reserve the right to request further documentation reasonably necessary to verify the nature and extent of any claim.

ADVANCED FUNDING

If the Employer needs to request advance funding, you must complete the Specific Excess Stop Loss Claim and Notification Form and provide the documentation required for reimbursement.

Advanced Funding can occur when the amount of claims paid meets the Specific Deductible. We will then consider advancing the difference between the Specific Deductible and the remaining amount of the claims.

We will consider advancing to the Employer any amount in excess of the Specific Deductible provided that:

  • The Employer has paid claims up to the Specific Deductible.
  • We receive adequate proof of loss within 30 days after such proof is received by the Employer.
  • We receive copies of claims adjudication and checks.
  • Advance Funding Requests must be $5,000 or more.

The policyholder's payment for covered expenses must be released to the provider within five business days of receiving the reimbursement check.

Any portion of the reimbursement check not used to reimburse covered expenses, due to additional discount or any other reason, must be returned to us within five business days.

Note: In the event that Advanced Funding is required near the end of the policy period, all requests must be received by us prior to 10 business days before the end of the policy period.

HOSPITAL BILL AUDITS

In the event a bill is received from a non-network provider and there is no discount negotiation, bills with total charges for ancillary services that are in excess of $50,000.00 may be sent for an audit pre-screen at our discretion.

We will also consider a pre-screen on hospital bills where the following appear excessive:

  • Diagnosis vs. length of stay
  • Type of ancillary charges.
  • Frequency of charges.

Billed ancillary services for pharmacy, laboratory, radiology, respiratory therapy and personal comfort items are the areas where frequent billing errors can occur. In addition, the following scenarios may indicate that a hospital audit should be performed:

  • Lab tests repeated more than once daily: Blood counts, urinalyses, SMA-12, CO'S or sodium potassium lab tests are not routinely given more than once a day.
  • Charges for blood transfusions with no credits for blood replaced or paid for; Check for surgery and the date of the transfusions. If no surgery was performed and/or the administration of blood is not consistent with the diagnosis, please question the charges.
  • Occupational/Physical therapy seems excessive: OT is not usually given more than once per day and PT more than twice in a day.
  • Inhalation therapy expense is high: Questionable when the patient is under age 50 and the diagnosis is other than respiratory and if the therapy is given more than once a day.
  • I.V. expenses appear excessive: Questionable when there are more than 3 charges per day, the necessity for I.V. is not consistent with the diagnosis and the frequency does not decline after a reasonable recovery period from surgery or after transfer from ICU/CCU.

Hospital bills with large ancillary charges may be considered for an audit pre-screen. In general we will pend 10% for hospital bills that reflect ancillary expenses that are in excess of $50,000.00.

SUBROGATION

When a medical plan pays the claims of a plan beneficiary and the plan beneficiary has a right to recover the amount the plan has paid from another source, a subrogation issue exists. If you have paid benefits for claims for which a third party (person, entity, insurance company or other) may be liable, you should pursue all valid claims you may have against the third party. If you fail to do so, and we become liable to make payment under this policy, we will pursue recovery of the subrogated amount.

CONSIDERATION FOR EXTRA-CONTRACTUAL BENEFITS / ALTERNATE TREATMENT PLANS

Under a self-funded plan and at the employer's discretion, exceptions may be made and benefits paid for services which are not covered under the employer's plan.

Reinsurance (Stop Loss coverage) is provided by a conventional carrier and only those expenses covered by the stop loss plan and as described in the employer's plan are covered.

Often, there are benefit limitations which may prevent cost-effective alternatives from being initiated. These situations generally occur when large case management is involved. When such a situation occurs, the claim must be reviewed by all risk bearersprior to payment. Risk bearers will indicate their position after the following steps have been completed:

  • The Employer has approved the out of contract recommendation.
  • The out of contract recommendation is an extension of a covered benefit under the Employer’s plan of benefits or is in lieu of a covered benefit. Savings can be captured when cost effective benefits not covered under this plan are substituted for existing benefits.
  • The cost savings are fully documented.

The purpose of an out of contract approval is not to extend coverage, but to utilize cost effective alternatives which constitute covered expenses under the plan of benefits.

AGGREGATE CLAIMS

AGGREGATE LOSS NOTIFICATION

You must give written notice of claims to Medical Risk Managers within 30 days of the date you become aware claims have reached 75% of the Annual Aggregate Attachment Point.

Aggregate claims should be filed within 60 days after the end of the policy period. An aggregate claim occurs when claims paid for covered benefits during a policy period exceed the greater of the Annual Aggregate Attachment Point or the Minimum Aggregate Attachment Point.

MONTHLY AGGREGATE BENEFIT OPTION

One of the benefit options offered is the Monthly Aggregate Benefit. This benefit provides monthly limits to the Employer's Aggregate claim liability. It also guards against mid-year claim fluctuations. The Employer does not need to wait until the end of the policy period to be reimbursed for eligible claims in excess of the Aggregate Attachment Point.

Beginning with the 3rd month of the policy period, any month in which the total claims paid to date exceeds the sum of A and B (as noted below) by at least $5,000.00, an advance payment of the Aggregate Stop Loss Benefit may be requested.

A. The greater of the year to date cumulative total of the monthly aggregate attachment points for the policy period, or the year to date minimum aggregate attachment point, and

B. Any previous advance(s)

If an Aggregate Stop Loss Benefit is determined as payable at the end of the policy period, it will be reduced by the total of the advances made, if any, under this benefit. The balance will then be paid.

If the amount(s) advanced under this benefit exceed the Aggregate Stop Loss Benefit, the Employer must remit the amount within 31 days of the date notified by Medical Risk Managers that payment is required.

If the Employer's coverage terminates before the end of the policy period, this benefit will automatically terminate, and a final reconciliation will be completed.

Medical Risk Managers does a quarterly reconciliation of advance payments. If applicable and once the reconciliation is completed, a refund will be requested.

Advances are not permitted in the final two months of the policy period.

AGGREGATE CLAIM SUBMISSION REQUIREMENTS

To file a monthly or annual claim, complete the Aggregate Claim Form and submit the required documentation.

Fill in the name and policy number of the Employer group, and the policy period for which the reimbursement request applies. Indicate the total claims paid amount, minus the aggregate attachment point. Deduct any specific claim reimbursements, any specific claim denials, any specific claims pending, any benefits paid outside the self-funded plan, and any payment adjustments. The final amount should be the amount of the aggregate reimbursement request.

Please include the following documentation:

Paid claims analysis:This form should include the claimant name, first and last date of service, payment amount, and payment date.

Check Register:The check register provides us with all payments made by the Plan. This report includes employee name, claimant name, incurred date, amount of payments/voids/refunds, check number, check date, and payee. This report is compared to the claim listing. The auditor verifies that the check date was issued and released within the policy period.

Claim listing (also known as the paid claim report): This report provides us with the year to date claim listing by claimant. The report should include the claimant’s name, date of service, procedure codes, provider’s name, discounts, non-covered, and paid amount. The auditor verifies that the claims processed are eligible. Once the report review is complete and the auditor has verified all charges are eligible, the total amount of the paid claims is compared to what the Plan has reported. Any claims considered “not covered” are withheld.

Funding Reports for the latest 13 months:This report includes the balance of the account at month’s end. The auditor verifies that enough funds were deposited to cover the claims paid by the plan within the policy period. These reports should include deposit tickets, and wire transfer statements.

Eligibility Listing:This report is listed by insured. It includes the insured’s date of hire, effective date of coverage, dependents, and type of coverage elected. The auditor uses this report to calculate the attachment point. Without this report we cannot verify the accuracy of the attachment point reported by the Plan. This report should include employee name, social security number, dependent names, date of hire, effective date of coverage, active or Cobra status, termination date.

Benefit Analysis:This summary provides us with the type of services and the total amount paid by the Plan within the policy period such as: prescriptions, surgery, administrative fees, anesthesia, office visit, dental, etc.

This report should include classification code, benefit type, and total benefit for code.

Rx Billing Summary: This report should include invoice date, amount, pharmacy name, and policyholder name.

Individual Payment Report:This summary is a listing of all claimants who have exceeded the Stop-Loss deductible. The auditor calculates each amount in excess of the specific deductible. Once this is complete the total amount of claims in excess of the specific deductible is deducted from the total paid claims. This report should include the claimant name, policy period, total claims, and the Specific Stop Loss Deductible.