SPECIFIC CLAIM GUIDE
NOTIFICATION REQUIREMENTS
SLG Benefits should be notified of potential
catastrophic losses or other large claims as soon as reasonably
possible. The procedures for notifying SLG Benefits are as follows:
Catastrophic Claims (using the Potential
Catastrophic Loss List)
Utilization Review (UR) vendors, Large Case Management (LCM)
vendors and TPAs should submit information regarding a catastrophic
claim to the SLG Benefits Risk Management Department as follows:
Phone: (800)-742-9779
Fax: (978)-740-9485
E-mail:
riskmanagement@slgbenefits.com
The information submitted will be carefully reviewed by our Risk
Management Staff. We may provide suggestions, if warranted, to
manage the claim effectively based on positive outcomes for the
patient at the most reasonable cost for the Plan Sponsor.
The Potential Catastrophic Loss List can be found in the Forms
Section of this Guide.
Standard Large Claim Notice (50% of the Specific
Attachment Point)
If a claimant has reached 50% of the Specific Attachment Point,
notification can be made using the Specific Claim Notification Form.
Upon completion, this form should be mailed to the address above or
may be sent via fax or e-mail as follows:
Fax: (978)-740-9485
E-mail:
riskmanagement@slgbenefits.com
Specific Excess Loss written notification is required by the Excess
Loss Insurance Policy with 30 days of the date the Plan Sponsor
becomes aware or as soon as practically possible. Timely
notification is required to assist us in establishing reserves and
to carefully track each claimant’s prognosis and disease state.
A sample
Specific Claim Notification Form (Specific Claim Form A- Claim
Notification or Initial Claim Filing Form) can be found in the
Forms Section of this Guide.
SPECIFIC CLAIM FILING PROCESS
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Specific claims are filed in one of two formats,
Traditional or Rapid File.
The Traditional File format consists of the basic claim data,
including the following:
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Enrollment and eligibility information;
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All itemized bills;
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Explanations of benefit (EOB’s)
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All other supporting documentation
The Rapid File format is designed for
pre-qualified TPA’s and is based on reducing the voluminous paperwork.
This format consists of the following claim submission:
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Enrollment and eligibility information;
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A computerized report in lieu of the individual
bills and corresponding EOB’s;
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All other supporting documentation
The computerized report referenced above provides
information in a format that typically captures the EOB and itemized
bill information. Please note, however, that even with the Rapid
File format we still require itemized bills and explanations for any
individual charge over $10,000.
SLG Benefits has an approval process that TPA’s must satisfy in order
to file claims in a Rapid File format. If approved, the TPA will be
subject to ongoing review to ensure acceptable claim accuracy
standards are continuously met. If we determine after any review that
there are serious concerns regarding claim adjudication, we will
reserve the right to suspend the TPA’s use of the Rapid File Format.
Unless the TPA has been pre-authorized to file claims using the
Rapid File format, your Specific claims must be filed using the
Traditional format.
I. FILING AN INITIAL
SPECIFIC CLAIM top
Once a claimant's paid eligible expenses under the
Plan exceed their Specific Attachment Point, a request for
reimbursement should be sent to SLG Benefits. A completed Specific
Initial Claim Filing Form along with the following documentation
should be submitted to SLG Benefits:
Traditional
Claim Submission
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Specific Claim Form A (Initial Claim Filing)
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Copy of employee's Enrollment Card, including the
date of hire and original effective date under the Plan
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Copy of the TPA's claim form if the claim is for
a dependent
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Complete details regarding eligibility and if
applicable, information regarding:
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Copies of Explanations of Benefit (EOB's)
attached to the corresponding itemized
bills (Note: All itemized bills should be date-stamped indicating
receipt date by the TPA.)
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Check copies, if not attached to the Explanation
of Benefit copy
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Completion of the Specific Advance Reimbursement
Form, if applicable
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Miscellaneous information as applicable
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Complete accident details including how, when
and where the accident occurred
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Police Report for Motor Vehicle Accidents or
for services for which a Law Enforcement agency is involved
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Subrogation and Right of Recovery Reimbursement
Agreement if charges were incurred as a result of third party
liability
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Coordination of Benefits (COB) documentation
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PPO discount calculations / Re-pricing sheets
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Large Case Management reports if applicable
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Student Verification information if the claim
is for a dependent over age 19
A
Liability Questionnaire,
Subrogation and Right of Recovery Agreement and
Higher Education Verification Form and can be found in the
Forms Section of this guide.
Rapid File
Claim Submission (Pre-approval required)
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Specific Claim Initial Filing Form
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Copy of Enrollment Card including date of hire
and the original effective date under the Plan
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Itemized provider bills for individual bills
exceeding $10,000 (a UB-92 summary bill will satisfy this
requirement for hospital charges)
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Copy of the TPA's Claim Form if the claim is for
a dependent
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Complete details regarding eligibility and if
applicable, information regarding:
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Completion of the Specific Advance Reimbursement
section if applicable
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System generated report containing the following
information:
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Employer/Group name
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Employee name
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Claimant name
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Provider name
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Date of Service and Payment Date
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Types of service
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Diagnosis or ICD-9 Code
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Deductibles and coinsurance application
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Ineligible or denied benefits with explanation
code
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Check numbers
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Charge amount and Payment amount
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PPO discounts
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Total payment line calculation
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Entries of voids and refunds when applicable
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Miscellaneous information as applicable
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Complete accident details including how, when
and where the accident occurred.
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Police Report for Motor Vehicle Accidents or
for services for which a Law Enforcement agency is involved
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Subrogation and Right of Recovery Reimbursement
Agreement if charges were incurred as a result of third party
liability
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Coordination of Benefits (COB) documentation
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PPO discount calculations / Re-pricing sheets
-
Large Case Management reports if applicable
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Student Verification information if the claim
is for a dependent over age 19
A
Liability Questionnaire &
Higher Education Verification Form can be found in the
Forms Section of this guide.
II. FILING A SUPPLEMENTAL
CLAIM top
The Specific Claim Form B (Supplemental Specific
Claim Filing) should be used with each subsequent claim filing after
the initial claim has been processed. This form was designed to reduce
the amount of time and paperwork necessary to file a claim after the
TPA had already established key items such as eligibility and claimant
information. Eligibility information, accident or Third Party
Liability information and claimant information may be omitted provided
there have been no changes since the initial or most recent
supplemental claim filing.
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Traditional Claim Submission
Supplemental claims should be submitted with items c-h listed in the
Traditional Claim Submission section above.
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Rapid File Claim Submission
Supplemental claims should be submitted with items c-h listed in the
Rapid File Claim Submission section above.
A sample
Specific Claim Form B (Supplemental Specific Claim Filing) can be
found in the
Forms Section of this Guide.
Filing Timelines
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The following timelines are established in the
insurance company Excess Loss Insurance Policy and we encourage
each TPA and Plan Sponsor to become familiar with these requirements
in order to avoid delay or forfeiture of a reimbursement.
Notice of Claim
SLG Benefits on behalf of the insurance carrier
must be provided with a written notice of claim within 30 days of the
date that the Plan Sponsor (or TPA) becomes aware of claims, with
respect to a Covered Person, that have reached 50% of the Specific
Attachment Point. Failure to furnish written notice within the time
required by the Policy will not invalidate or reduce any claim if it
was not reasonably possible to provide written notice within such time
frame. However, written notice must be furnished as soon as possible,
but in no event later than one year after the date written notice is
first required. Large Claims and Potentially Catastrophic Losses
should be reported (regardless of whether charges have been Paid or
are Pending Payment) as soon as practically possible.
Proof of Loss
SLG Benefits on behalf of the insurance carrier
must receive written Proof of Loss within 60 days after the date of
loss. Late proof will be accepted only if it is shown to have been
furnished as soon as reasonably possible and within one year of the
date of loss.
Payment of Claims under the Excess
Loss Insurance Policy
Amounts payable under the Policy will be paid upon
receipt and acceptance by SLG Benefits of all the required material.
Required material shall include proof of loss and proof of Payment for
Eligible Expenses under the Plan and any reasonable requested
supporting documentation. SLG Benefits on behalf of the insurance
company will have sole authority to reimburse or deny claims under
the Policy.
Benefit Determinations
Determination of benefits under the Plan is the
sole responsibility of the Policyholder. SLG Benefits on behalf of the
insurance company has no duty to settle or adjust claims filed
under the Plan. We reserve the right to review each claim submitted
for reimbursement to determine if the Policyholder is entitled to
reimbursement under the Excess Loss Insurance Policy. SLG Benefits on
behalf of the carrier will have sole authority to
reimburse losses covered by the Policy.
III. FILING A SPECIFIC
ADVANCE REIMBURSEMENT REQUEST
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SLG Benefits, on behalf of the carrier, realizes
that occasionally groups may have difficulty paying large provider
bills, particularly when a prompt pay or time sensitive PPO discount
may be involved. In an effort to assist our clients in meeting their
financial needs, SLG offers access to our Specific Advance
Reimbursement program. This value-added service provides tremendous
cash-flow peace of mind in these financially stressful situations.
SLG Benefits must receive written notice of Specific Advance
Reimbursement requests no more than (7) seven calendar days after
the expiration date of the Excess Loss Insurance Policy, in order
for the Plan Sponsor to be excused from actual payment according to
the terms of the Policy. Any special exceptions must be submitted in
writing to SLG Benefits prior to the end of the (7) seven day period
after the expiration date of the Policy.
A fully completed and signed
Specific Initial or
Supplemental Claim Filing Form, along with the
Specific Advance Reimbursement Form (or Combination Form) is
required with each Advance Reimbursement request. As this is a
specialized service program designed as a cash flow tool for the Plan
Sponsor, we respectfully request that requested Specific Advance
Reimbursement amounts be equal to or greater than $1,000.
The following conditions must be satisfied in order for us to consider
a Specific Advance Reimbursement Request. These items are also
outlined on the
form which can be found in the
Forms Section of this Guide:
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The form must be completed and submitted with
each Specific Claim Advance Reimbursement request.
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The Claim Administrator, prior to the expiration
of the Specific Excess Policy, must process all eligible bills
relating to this Advance Reimbursement request.
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Checks totaling at least the amount of the
Specific Attachment Point must be processed, paid and released to
the indicated providers prior to the expiration of the Specific
Policy or prior to this request, whichever is earlier.
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Premium must be paid through the month in which
the claim is submitted.
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Advance Reimbursement requests will not be
accepted if received more than (30) thirty days after the date of
the Policy’s cancellation or premature termination.
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All eligible Expenses must be immediately
released to providers upon our payment of the claim.
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The claim request for Specific Advance
Reimbursement must be greater than $1,000.
SPECIAL
NOTE
The Excess Loss Insurance Policy is written on
reimbursement basis only. This means the Plan Sponsor is responsible
for paying all eligible claim expenses prior to filing a reimbursement
request. Specific Advance Reimbursement assists clients with payment
of large medical charges only and does not change any of the terms or
provisions of the Policy.
Therefore, if requesting Specific Advance Reimbursement, it is
critical that all guidelines outlined above are carefully followed. If
these guidelines are not followed, your Specific Claim Reimbursement
submission will be handled strictly on a reimbursement basis. This
could lead to delays in receiving reimbursement or potential claim
denials if claims have not been Paid within the terms of the Policy
Period.
SPECIFIC TERMINAL
LIABILITY OPTION top
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:
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Available on the following contracts: 12/12,
15/12, 18/12, 24/12 and Paid
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Coverage is not applicable upon early termination
of the group’s Excess Loss Policy
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Product is intended for expiring Policyholders
who are returning to a fully insured arrangement
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Not available at renewal unless elected on the
group’s original effective date
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