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Specific Stop Loss Claim Notification

for Traditional Products.

  1. WHAT IS A SPECIFIC STOP LOSS CLAIM NOTIFICATION?
    • This type of notice occurs when an employee or dependent has the potential to be a specific claim.
  2. WHAT IS THE PURPOSE OF SPECIFIC STOP LOSS CLAIM NOTIFICATION?
    • Allows for preparation of the potential specific claim.
    • Allows for preparation of setting a reserve for the potential specific claim.
    • Allows TPAC Underwriters, Inc. the opportunity to review the potential claim for advice on medical management of claims that involve long term and/or large dollar liabilities.
  3. WHEN TO SUBMIT A SPECIFIC STOP LOSS CLAIM NOTIFICATION.
    • When a covered individual exceeds 50% of the stop loss policy specific deductible.
    • When the administrator receives information indicating one of the diagnosis listed on the Trigger Diagnosis List. This information may be on a bill, a pre-certification notice or a case management referral.
    • When an administrator receives information of a potential lengthy inpatient confinement. A lengthy confinement would be considered as any confinement in excess of seven days. An administrator will usually receive notice of this through the pre-certification process.
  4. WHAT TO SUBMIT
    • The TPAC Underwriters, Inc. Specific Claim Form can be used for both specific claim notices and specific claim submissions.
    • If applicable, all case management information.
    • If applicable, all pre-certification information.
    • Any information that the administrator feels may indicate a potential large specific claim.