OHIO HEALTH REINSURANCE PROGRAM (OHRP)
CLAIM REIMBURSEMENT REQUEST FORM

When claim payments have exceeded any applicable deductibles, this form along with all required documentation, should be completed and submitted to:

Self-Funded Plans, Inc.

Attention: Lori Ziegler

1432 Hamilton Avenue

Cleveland, OH 44114

Telephone: (216) 377-7152

Fax: (216) 566-1505

Email:

Please complete the following and submit with the information listed below:

Carrier Name:

Reinsured Name:

Reinsured/Employee Social Security Number:

Reinsured Date of Birth:

Total Amount Paid by Carrier:

We require claims payment detail which must include at least the following information:

  1. Reinsured name
  2. Provider in or out of network (for PPO plan only)
  3. Diagnosis code
  4. Service code
  5. Dates of service
  6. Units (days, visits, etc.)
  7. Place of service
  8. Charge amount
  9. Allowed amount
  10. Paid amount (carrier liability)
  11. Paid date

PLEASE NOTE: IN ORDER TO PROCESS THE CLAIM REIMBURSEMENT REQUEST, WE MUST RECEIVE BOTH THE COMPLETED FORM AS WELL AS THE CLAIM PAYMENT DETAIL LISTING/REPORT.

I certify that, to the best of my knowledge, the above information is correct and the claim has been paid in accordance with the Plan Document.

Submitted by:

Telephone:

Fax:

e-mail:

CARRIER CLAIMS CERTIFICATION

Ohio Health Reinsurance Program – Small Employer

As a member carrier in the Ohio Health Reinsurance Program (OHRP) Small Employer Pool, I hereby certify that this claim is being submitted only to the OHRP Administrator, Self-Funded Plans, Inc. This claim has not been submitted to Summit Administrative Services, Inc. for payment.

I certify that I am an Officer of the undersigned Insurer/Carrier.

(NOTE: THIS CERTIFICATION MUST BE SIGNED BY AN OFFICER OF THE CARRIER.)

______

Signature of Officer

______

Printed Name of Officer

______

Insurance Co./Carrier Name

______

Officer’s Title/Office

Date: ______

CARRIER CLAIMS CERTIFICATION

Ohio Health Reinsurance Program – Open Enrollment

As a member carrier in the Ohio Health Reinsurance Program (OHRP) Open Enrollment Pool, I hereby certify that this claim is being submitted only to the OHRP Administrator, Self-Funded Plans, Inc. This claim has not been submitted to Summit Administrative Services, Inc. for payment.

I certify that I am an Officer of the undersigned Insurer/Carrier.

(NOTE: THIS CERTIFICATION MUST BE SIGNED BY AN OFFICER OF THE CARRIER.)

______

Signature of Officer

______

Printed Name of Officer

______

Insurance Co./Carrier Name

______

Officer’s Title/Office

Date: ______

10/6/2018