SPECIFIC CLAIMS

AGGREGATE ACCOMMODATIONS

AGGREGATE CLAIMS

SPECIFIC CLAIMS

Specific claims will be reimbursed according to the stop loss contract, the plan document benefits and provisions, payment accuracy, investigative results and claimant eligibility. If an investigation was conducted we will require a copy of all correspondence and responses.

Claimant eligibility will be based on employment status, underwriting disclosure, COBRA participation and dependent eligibility provisions of the plan.

On claims involving a third party we will require accident details, police reports, other insurance information, a signed subrogation agreement and the name and phone number of the claimant's attorney. This information will be forwarded to an attorney who will pursue a subrogated recovery on behalf of the stop loss carrier and the group. There is no charge to the TPA or group for pursuit of a recovery.

FILING A 50% NOTICE

Our Specific Stop Loss Claim form must be completed to notice us when total claims reach or exceed 50% of the Specific deductible. Even if advance notice of a potential claim was provided to OCM based upon a trigger diagnosis or hospital confinement, we must be notified when the claim reaches 50% of the Specific deductible. This notification will assist us in setting claim reserves.

FILING A SPECIFIC CLAIM

A completed Specific Stop Loss Claim form and all relevant supporting documentation, as listed on the claim form, must be submitted for consideration of any reimbursement on Specific Claims. The Specific Claim Submission checklist is provided as a guideline to ensure that a submission is complete.

AGGREGATE ACCOMMODATIONS

FILING AN ACCOMMODATION (Monthly Paid Aggregate Accommodation Claim Request)

A completed Monthly Paid Aggregate Accommodation Claim Request form should be submitted to our Claims Department with:

• An eligibility listing including the original effective dates with the plan, termination dates, COBRA participants, dependent names and dates of birth.

• A paid claims report for the period.

After the initial MPA filing, only a paid claim report for the succeeding month will be required.

MPAs must be filed within 30 days of the period being reported in order to be eligible for reimbursement.

Once the MPA has been paid, it will be necessary to file every month until the entire accommodation is refunded to the stop loss carrier or the 11th month of the policy period - whichever comes first.

No accommodations will be made after the 11th month of the policy period. In the final month of the contract, a determination will be made on whether an aggregate claim has occurred. (See Filing an Aggregate Claim). The final MPA will be treated as an aggregate claim.

AGGREGATE CLAIMS

FILING AN AGGREGATE CLAIM

A completed Aggregate Claim Request form should be submitted to our Claims Department with:

• A detailed paid claims report reflecting claims paid for each individual claimant; incurred and paid dates; and service and diagnosis codes.

• An eligibility listing showing the original effective dates with the plan; termination dates; COBRA participants; dependent names and dates of birth.

• A report of voids and refunds for the policy period.

• Check registers by month for the policy period.

• Proof of funding of the final check register.

• Copies of COBRA election forms and proof of payment for all COBRA participants with claims paid included in this request.

• Notification of outstanding subrogation issues

AUDIT SCHEDULING

Upon receipt of the claim and supporting documentation, a review will be made to determine if an on-site audit will be necessary. The decision to refer the aggregate claim to an outside auditing firm is based on:

• Total paid claims for the policy period.

• The TPA's past claims processing and payment accuracy.

• Our volume of aggregate claims pending audit.

The majority of claims with a requested reimbursement of less than $25,000 will usually be reviewed through a local desk audit.

Only reputable audit firms with proven capability, prompt audit scheduling history and timely reporting are selected to perform on-site aggregate audits. Typically, the audit firm schedules the audit within 15 days of receiving the assignment.

Reference may be made to the on-site audit report when we issue our reimbursement. We will always include a copy of our Aggregate Reimbursement summary, which outlines our final determination on the results of the audit.

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