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Specific Stop Loss Claims

for Traditional Products

  1. WHAT IS A SPECIFIC STOP LOSS CLAIM?
    • This type of claim occurs when an employee or dependant has had medical claims paid by their employer in excess of the amount specified in the Excess Loss contract.
  2. HOW TO SUBMIT A SPECIFIC STOP LOSS CLAIM
    • The original claim should be completely processed by the Administrator, it should be submitted to TPAC after the Specific Deductible has been exceeded, along with a completed “Specific Claim Form” (alternate forms may be used if they contain the necessary information).
    • TPAC will review the claim and issue any reimbursement payable to the employer’s benefit fund for the amount that the claim exceeds the Specific Deductible. All checks will be mailed directly to the Administrator.
    • Additional eligible expenses should be accumulated and processed once a month or when an additional minimum of $500 in expenses has been incurred, whichever comes first. The Administrator should inform each employer that such bills will be accumulated and processed in this manner.
  3. WHAT TO SUBMIT
    • The entire claim filed with the Administrator should be submitted. All items must de dated stamped and in chronological order based on the date the Administrator received the expenses. The claim file should include a completed claim from which contains an employee statement. It is recommended that the Administrator receive a completed claim form at least once every 12 months.
    • All worksheets completed by the Administrator.
    • Itemized bills for all expenses. Balance due statements, cash register receipts and cancelled checks are not eligible for consideration.
    • All correspondence, memorandums and telephone messages related to the claim file.
    • Calculations used for determination of usual and customary fees.
    • All details regarding investigation of eligibility and coordination of benefits.
    • Copies of claim checks or drafts issued by the Administrator.
    • Copies of enrollment Card/Forms with the employee’s original effective date of coverage.
  4. SPECIAL HANDLING, COMMENTS AND RECOMMENDATIONS
    • Referral should be made to TPAC for advice on medical management of claims that involve long term and/or large dollar liabilities.
    • File documentation is critical. Claims will not be considered if they are not properly documented with fully completed claim forms and itemized bills.
    • All documents must be date stamped when received by the Administrator. All claims should be processed in a timely manner.
    • TPAC must be advised in writing as soon as possible of any law suit in which they are named or could become involved because of Excess Loss Coverage.
    • Claims involving unusual claim situations (i.e. fraud or suspected fraud, unusual medical procedures or practices, purchase vs. rental of major equipment, etc.) should be referred to TPAC, prior to payment, for review and recommendation.
    • All files and records that may impact Excess Loss claims are subject to on site and or mail audit.