THE SLG RISK MANAGEMENT PROCESS

A cornerstone of the SLG Benefits & value proposition is to provide our producers and claim payers with risk management tools. Once a new case is sold or an existing account is renewed, our medical staff will monitor potential high dollar claims and offer medical services to supplement the TPA's medical expertise. These services include case management oversight and facilitation of referrals to outcome-based transplant networks, claims negotiators, re-pricing vendors and specialty risk management vendors such as Pharmacy Benefit Managers and Neonatal specialists. We have invested resources into vetting these vendors to find those we believe to be the best in their individual designation based on outcomes and cost management. Our goal is to ensure that the claimant always receives the highest quality of care at the most appropriate cost.

Communication between the TPA, the UR vendor and our medical staff is the most critical component of the claim management process. Early notification is extremely important to SLG Benefits and is typically reflected in our stop-loss pricing. The initial referral regularly comes from the Utilization Review vendor based on the Potentially Catastrophic Loss List. This list consists of specific diagnoses that are key indicators of potentially catastrophic losses and acute medical situations that warrant close review and may require case management consultation. The claims administrator is also expected to notify SLG Benefits as soon as a claimant is identified as high risk, based on the Potentially Catastrophic Loss List or they feel has the potential to reach 50% of the specific deductible.

The Potentially Catastrophic Loss List can be found in the Forms Section of this Guide.

Referrals may be sent to the SLG Benefits Risk Management Department as follows:

Phone: 800-742-9279
Fax: 978-740-9485
E-Mail: riskmanagement@slgbenefits.com

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

When we receive notification of a potentially catastrophic case, our medical staff will do an initial assessment of the patient's medical condition and treatment plan. The case and treatment plan will typically be discussed with the TPA or existing case manager. After completing our assessment, we typically designate the claimant into 1 of 3 categories:

Our medical staff reviews the case and determines that the estimated costs of treatment will not be significant and case management intervention is not indicated. Patient eligibility issues are verified, specific provider network arrangements reviewed and initial claims are analyzed. Our medical staff may monitor the case at specific intervals and will ask to be notified if claim activity increases so that the situation can be re-assessed if necessary.

Our medical staff determines that the claimant may require case management intervention or be a candidate for a referral to a specialty risk management vendor. Patient eligibility issues are verified, specific provider network arrangements reviewed and initial claims are analyzed. The case will typically be followed by a case manager assigned by the UR vendor or TPA. SLG Benefits may also make a case management recommendation if needed. Our medical staff will monitor the case and act as a resource to assist with services such as claim negotiations and access to specialty networks. The case will be followed regularly during the remainder of the Policy Year.

Our medical staff determines that there is significant potential for a catastrophic claim. Patient eligibility issues are verified, specific provider network arrangements reviewed and initial claims are analyzed. The case is then assessed for the most appropriate case manager based on the specific diagnosis and treatment plan. Throughout the claimant's episode of care, we expect the case manager to maintain close communication with the SLG Benefits medical staff. Our medical staff will review all case management data, recommend additional interventions and remain available as a valuable resource.