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AGGREGATE CLAIM GUIDE

TPA MONTHLY REPORTING REQUIREMENTS

SLG Benefits on behalf of the insurance carrier requests that all TPAs report on or before the 15th day of each Policy Month, the following data for the preceding Policy Month:

1. Number of Covered Persons and/or Covered Units; and

2. A total of claims Paid

Most TPA’s have an automated Aggregate Claim Report that summarizes the information listed above. Please feel free to submit your report.

A sample Aggregate Reporting Form can be found in the Forms Section of this Guide.

FILING A YEAR END AGGREGATE CLAIM

In order to file a Year End Aggregate Claim for reimbursement under the Policy, we ask that the TPA gather the following required documentation:

• Completed Year End Aggregate Claim Form

• Paid Claims Analysis Report showing claimant name, date of service, type of service, amount charged and amount, date and Payee for each Payment made

• Eligibility listing which identifies date of birth, effective date, termination date and coverage type

• Proof of funding, including bank statements and/or deposit slips *

• Void & Refunded Claim Report *

• Benefit/Service Code report

• Aggregate Report (Monthly Loss Summary Report)

• Specific Claim Report showing claimants that have exceeded the Individual Attachment Point / Individual Claim Limit

• Listing of payments made outside the Aggregate Policy (i.e. Dental, Weekly Income, Vision, PPO Fees, Medical Records Fees, Capitated Fees, PCS (RX) Administrative Fees)

• Check Register

• Outstanding overpayment and subrogation log *

• Rx Card invoices if Rx Card is covered under the Aggregate Policy

* SLG may also request this information for the month or two following expiration of your excess- loss Policy to review for retroactive adjustments.

Once the TPA has completed the Claim Form and compiled all of the information above, we request that this package of information be sent immediately to SLG Benefits at the following address:

SLG Benefits and Insurance, LLC
9 Atlantic Avenue
Marblehead, MA 01945

Phone: (800) 742-9279
Fax: (978) 740-9485

A Sample Year End Aggregate Claim Form can be found in the Forms Section of this Guide.

AGGREGATE ACCOMMODATION OPTION

Aggregate Accommodation is offered as an option to our smaller group clients to provide greater cash flow and financial protection for the largest dollar segment of their health plan. Any Accommodation is at all times, to be considered funds of the Carrier for which the use by the Policyholder of such funds is provided by Endorsement to the Policy. The Aggregate Accommodation should not be construed as a loan or cash advance.

If in any month during the Policy Period, the total Plan Benefits Paid by the Policyholder, for which reimbursement is provided under the Policy, exceeds the sum of:

1. the greater of (a) the accumulated Annual Aggregate Attachment Point or (b) the pro rata of the portion of the Minimum Annual Aggregate Attachment Point; and

2. any previous advances; and

3. $1000;

Then the Policyholder may request an advance of the aggregate excess benefit.

Accommodation Filing Requirements

In order to file an Aggregate Accommodation request we require the submission of the following documentation:

1. Completed Monthly Aggregate Accommodation Form

2. Monthly Loss Summary Reports showing the Policyholder's monthly paid claims data and aggregate census information

3. Paid Claims Analysis Report showing claimant name, date of service, type of service, amount charged, and amount, date and Payee for each Payment made

Accommodation Filing Procedures

• All claims must be Paid by the Plan Sponsor prior to applying for an Aggregate Accommodation.

• Aggregate Accommodation requests must be received by SLG Benefits within 20 days following the end of the month for which the accommodation is requested.
  (For example, if you are filing for the month of July, then we must receive your request no later than August 20th.)

• Aggregate Accommodation must be greater than our service minimum requirement
  of $1,000.

• Aggregate Accommodation is not available in the final month of the Policy or during a run-out provision.

• The initial request for Aggregate Accommodation cannot be made prior to the end of the 90 day period following the first day of the Policy Period.

Reconciliation Procedures

If the Policyholder has not incurred an aggregate claim at the end of the Policy year, then the Policyholder must refund all Aggregate Accommodations. If the year-to-date claims fall below the accumulated aggregate deductible in any given month, all Accommodation advances must be refunded in the following month.

Failure to repay any overpayment within 60 days after written notice is provided shall result in either a 10% penalty per annum or a reduction of subsequent reimbursements under the Aggregate or Specific Excess Loss benefits by the amount of the overpayment.

SLG Benefits reserves the right to audit all records affecting our liability under this Policy.

AGGREGATE TERMINAL LIABILITY OPTION

This product provides three months run-out protection for those claims incurred during the current Policy Period. It may be utilized in adherence with the following parameters:

• Available on the following contracts: 12/12, 15/12, 18/12, 24/12 and Paid

• Coverage is not applicable upon early termination of the group’s Excess Loss Policy

• Product is intended for expiring policyholders who are returning to a fully insured
  arrangement

• Not available at renewal unless elected on the case’s original effective date

• Coverage cost is commissionable and varies depending on the commission level selected

In conjunction with the extended coverage, the Monthly Aggregate Factors are increased by a factor of 1.25. Coverage is triggered upon expiration of the Excess Loss Insurance Policy. SLG Benefits will issue a Terminal Liability Policy Endorsement illustrating the modified Monthly Aggregate Factors and Minimum Annual Aggregate Attachment Point.