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Claim Philosophy
Alliance Underwriters will:
- give fair and equitable consideration to all claims
- reimburse claims quickly and accurately, or provide easily understood reasons for delay or denial of any claim
- handle all written and verbal communications with professionalism and courtesy
- actively promote cost containment, using a team approach including Oversight Case Management and the third party administrator; thereby protecting the interests of our reinsurers
- continuously work toward the development of new techniques and more efficient methods of auditing and reimbursement
- continuously educate our claims staff in insurance and reinsurance industry issues and provide opportunities for the continuing education of our third party administrators and their staff
A reasonable effort should be made to follow the recommendations of UR/LCM firms. These professionals serve to advise, seek and
sometimes arrange the most economical means of purchasing services and products without compromising the quality of care.
In all cases, however, final decisions regarding coverage rest with the self-funded employer (plan sponsor). ERISA dictates that the
plan sponsor is responsible for handling plan assets in a prudent manner.
It is recognized that the employer may delegate the plan administration to a third party administrator who will likely advise the plan
sponsor on various issues; none-the-less, the plan sponsor will make the final decision regarding plan benefits.
As long as the employer's decision regarding benefits is in compliance with the plan document, Alliance Underwriters, on behalf of the
stop loss carrier, is bound to reimburse any stop loss claims according to the terms of the stop loss contract. Should the employer's
decision regarding a benefit issue result in a stop loss claim being paid outside the plan document or the stop loss contract, such will
be considered the right of the self-insured employer. However, the stop loss carrier is not bound by such decision to reimburse benefits
outside the plan document or stop loss contract.
If the plan document provides a benefit and the stop loss contract is silent on that benefit, then the plan provision will prevail. Any
claims paid by the plan administrator for the benefit will be considered for reimbursement under the stop loss contract.
If the plan document provides a benefit that is excluded under the stop loss contract, then the stop loss contract will prevail. Any
claims paid by the plan administrator for the benefit will not be considered for reimbursement under the stop loss contract. If both the
plan document and the stop loss contract are silent on a benefit, reimbursement under the stop loss contract will be based upon Alliance
Underwriters' medical necessity determination and current industry standards and practices, as stated in:
- the Trilogy Claims Administration Handbook
- publications on Medicare coverage guidelines and issues
- an industry surgical unbundling guidebook
- Physician's Current Procedural Terminology
- Physician's Desk Reference
- RBRVS
- Milliman and Robertson
- compendia - AHFS-DE, AMA-DE, USP-DI
and other industry publications.
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