MEDICAL RISK MANAGERS
STOP LOSS CLAIMS ADMINISTRATION GUIDE
TABLE OF CONTENTS
Introduction
Address for Claim Submissions
Contact
Forms
Specific Claims
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General Conditions
Large Claim Notification
Specific Claim Submission Requirements
Advanced Funding
Hospital Bill Audits
Subrogation
Extra-Contractual Benefits
Aggregate Claims
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General Conditions
Aggregate Loss Notification
Monthly Aggregate Benefit Options
Aggregate Claim Submission Requirements
Aggregate Claim Review – Desk Audit
Aggregate Claim Review – On-Site Audit
Reimbursements
Appendix: Electronic Claim Submissions
Appendix: Catastrophic Conditions by Diagnosis
1
INTRODUCTION
This document should be used as a guide for Stop (Excess) Loss Claim submissions. Each claim will be reviewed
independently. Reimbursement will be based on the claim documentation received and/or requested as it relates
to the Plan and Stop-Loss Policy provisions.
ADDRESS FOR CLAIM SUBMISSIONS
Claims Department
Medical Risk Managers, Inc.
1170 Ellington Road
South Windsor, CT 06074
Ph: 860-732-3248 Fax: 860-282-4019
Via Email: [email protected]
CONTACTS
General Questions
Donna Carter
Claims Manager
860-291-3083
[email protected]
Claim Status
Amy Lugo
Senior Auditor
860-291-3084
[email protected]
FORMS
Please use the following Excel forms to submit your claim reimbursement request (double-click the icon to open
the embedded form.)
Specific Claim and Notification Form:
Specific Claim and
Notification Form.xlsx
Aggregate Claim Form:
Aggregate Claim
Form.xlsx
Bank Wire Instructions:
Bank Wire
Instructions Form.xlsx
2
SPECIFIC CLAIMS
GENERAL CONDITIONS
Only payments made within the contract period and in accordance with the approved Employee Benefit Plan are
reimbursable. Claims shall be deemed paid on the date that the payer directly tenders payment.
As you receive additional claim information, please continue to update the estimate of total cost in order for our
reserves to be as accurate as possible.
Medical Risk Managers must be notified prior to the expiration of the contract of any claim that is being
investigated or is pending for final benefit determination. If written notice is received, reviewed and approved
prior to the expiration of the contract, consideration of this claim normally will be given. We reserve the right to
disallow any claim that is not properly and contractually paid within the terms of the contract.
If this contract should terminate or expire, we shall not be liable for Specific Benefits concerning expenses paid
after the termination date of the expiration date of the contract, whichever occurs first.
In no event will the Specific Benefit with regard to any covered person exceed the maximum benefit shown in the
application/schedule.
LARGE CLAIM NOTIFICATION
We are required to provide notification of potentially large claims to the Stop Loss Carrier and Risk Bearers on a
monthly basis. Please use the Specific Excess Loss Claim and Notification Form to provide us with a large claim
notification when the following occurs:
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When you are notified of a pre-certification or receive a potential large claim, please refer to the
Appendix containing a list of Catastrophic Conditions by Diagnosis.
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When you are notified of a potential transplant recipient.
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When a claim reaches 50% of the Specific Deductible level.
SPECIFIC CLAIM SUBMISSION REQUIREMENTS
Once a claim has exceeded the Specific Deductible, a request for reimbursement should be submitted to Medical
Risk Managers using the Specific Excess Loss Claim and Notification Form. Please indicate if you are requesting
advance funding. Claim submission requests should include the following documentation:
Employee Enrollment Form: Please provide a copy of the original signed and dated enrollment card. This
document should indicate date of hire, original effective date of coverage, termination date, and current
work status. A copy of the payroll record may be requested.
COBRA Election Form: If coverage has been cancelled, please provide the COBRA Election form and proof
that COBRA premium payments have been paid to date.
Explanation of Benefits or Individual Payment Report: This report must include the First and Last name
of the claimant, date(s) of service, provider name, diagnosis, procedure code, received and paid date,
total charges, discounted and/or allowable charges, deductible and co-insurance. A copy of the claim
check/draft/wire must be submitted if details are not provided in the Explanation of Benefits. Detailed
itemization must be included for hospital claims in excess of $50,000.
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Proof of Deductible and Coinsurance: If a plan has a deductible or co-insurance amount which needs to
be met each calendar or benefit year, we require proof that these amounts were met. If not, we will
withhold the outstanding amount until we receive proof.
Large Case Management Reports: If case management has been implemented we will require a copy of
the report. This document gives the auditor a review of the claimant condition. It may also give details of
the treatment plan and future estimated cost
UB-92 and HCFA Forms: Copies of the physician and hospital bills
Pre-Certification forms: This form verifies that the in-patient confinement dates were authorized. It also
includes the length of stay versus approved days. We will request a copy of the pre-certification form for
each hospital confinement. If authorization was not given, we will pend the amount of the penalty until
we receive a copy of the authorization.
Accident/Police Reports: For all accidental claims, we will need a copy of the police report and/or details
of the accident. We also require a copy of the signed subrogation agreement, if applicable
For investigational purposes the following may be required:
COB Forms
Pre-existing Condition Info
Worker’s Compensation Forms
Employee Claim Form
Medicare Election Form
Divorce, Separation, or Court Decree papers
Eligibility Questionnaire
Full Time Student Status
Subrogation Forms
Additionally, please submit copies of all documentation that had an effect on consideration and payment of the
claim (for example: copies of medical records and operative reports.
Claim form(s) and documentation can be emailed, mailed, or faxed to the address provided at the beginning of this
document.
We reserve the right to request further documentation reasonably necessary to verify the nature and extent of any
claim.
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ADVANCED FUNDING
If the Employer needs to request advance funding, you must complete the Specific Excess Stop Loss Claim and
Notification Form and provide the documentation required for reimbursement.
Advanced Funding can occur when the amount of claims paid meets the Specific Deductible. We will then consider
advancing the difference between the Specific Deductible and the remaining amount of the claims.
We will consider advancing to the Employer any amount in excess of the Specific Deductible provided that:
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The Employer has paid claims up to the Specific Deductible.
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We receive adequate proof of loss within 30 days after such proof is received by the Employer.
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We receive copies of claims adjudication and checks.
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Advance Funding Requests must be $5,000 or more.
The policyholder's payment for covered expenses must be released to the provider within five business days of
receiving the reimbursement check.
Any portion of the reimbursement check not used to reimburse covered expenses, due to additional discount or
any other reason, must be returned to us within five business days.
Note: In the event that Advanced Funding is required near the end of the policy period, all requests must be
received by us prior to 10 business days before the end of the policy period.
HOSPITAL BILL AUDITS
In the event a bill is received from a non-network provider and there is no discount negotiation, bills with total
charges for ancillary services that are in excess of $50,000.00 may be sent for an audit pre-screen at our discretion.
We will also consider a pre-screen on hospital bills where the following appear excessive:
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Diagnosis vs. length of stay
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Type of ancillary charges.
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Frequency of charges.
Billed ancillary services for pharmacy, laboratory, radiology, respiratory therapy and personal comfort items are
the areas where frequent billing errors can occur. In addition, the following scenarios may indicate that a hospital
audit should be performed:

Lab tests repeated more than once daily: Blood counts, urinalyses, SMA-12, CO'S or sodium
potassium lab tests are not routinely given more than once a day.
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Charges for blood transfusions with no credits for blood replaced or paid for; Check for surgery and
the date of the transfusions. If no surgery was performed and/or the administration of blood is not
consistent with the diagnosis, please question the charges.
5
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Occupational/Physical therapy seems excessive: OT is not usually given more than once per day and
PT more than twice in a day.
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Inhalation therapy expense is high: Questionable when the patient is under age 50 and the diagnosis
is other than respiratory and if the therapy is given more than once a day.
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I.V. expenses appear excessive: Questionable when there are more than 3 charges per day, the
necessity for I.V. is not consistent with the diagnosis and the frequency does not decline after a
reasonable recovery period from surgery or after transfer from ICU/CCU.
Hospital bills with large ancillary charges may be considered for an audit pre-screen. In general we will pend 10%
for hospital bills that reflect ancillary expenses that are in excess of $50,000.00.
SUBROGATION
When a medical plan pays the claims of a plan beneficiary and the plan beneficiary has a right to recover the
amount the plan has paid from another source, a subrogation issue exists. If you have paid benefits for claims for
which a third party (person, entity, insurance company or other) may be liable, you should pursue all valid claims
you may have against the third party. If you fail to do so, and we become liable to make payment under this
policy, we will pursue recovery of the subrogated amount.
CONSIDERATION FOR EXTRA-CONTRACTUAL BENEFITS / ALTERNATE TREATMENT PLANS
Under a self-funded plan and at the employer's discretion, exceptions may be made and benefits paid for services
which are not covered under the employer's plan.
Reinsurance (Stop Loss coverage) is provided by a conventional carrier and only those expenses covered by the
stop loss plan and as described in the employer's plan are covered.
Often, there are benefit limitations which may prevent cost-effective alternatives from being initiated. These
situations generally occur when large case management is involved. When such a situation occurs, the claim must
be reviewed by all risk bearers prior to payment. Risk bearers will indicate their position after the following steps
have been completed:

The Employer has approved the out of contract recommendation.

The out of contract recommendation is an extension of a covered benefit under the Employer’s plan of
benefits or is in lieu of a covered benefit. Savings can be captured when cost effective benefits not
covered under this plan are substituted for existing benefits.

The cost savings are fully documented.
The purpose of an out of contract approval is not to extend coverage, but to utilize cost effective alternatives
which constitute covered expenses under the plan of benefits.
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AGGREGATE CLAIMS
AGGREGATE LOSS NOTIFICATION
You must give written notice of claims to Medical Risk Managers within 30 days of the date you become aware
claims have reached 75% of the Annual Aggregate Attachment Point.
Aggregate claims should be filed within 60 days after the end of the policy period. An aggregate claim occurs when
claims paid for covered benefits during a policy period exceed the greater of the Annual Aggregate Attachment
Point or the Minimum Aggregate Attachment Point.
MONTHLY AGGREGATE BENEFIT OPTION
One of the benefit options offered is the Monthly Aggregate Benefit. This benefit provides monthly limits to the
Employer's Aggregate claim liability. It also guards against mid-year claim fluctuations. The Employer does not
need to wait until the end of the policy period to be reimbursed for eligible claims in excess of the Aggregate
Attachment Point.
Beginning with the 3rd month of the policy period, any month in which the total claims paid to date exceeds the
sum of A and B (as noted below) by at least $5,000.00, an advance payment of the Aggregate Stop Loss Benefit
may be requested.
A. The greater of the year to date cumulative total of the monthly aggregate attachment points for the
policy period, or the year to date minimum aggregate attachment point, and
B. Any previous advance(s)
If an Aggregate Stop Loss Benefit is determined as payable at the end of the policy period, it will be reduced by the
total of the advances made, if any, under this benefit. The balance will then be paid.
If the amount(s) advanced under this benefit exceed the Aggregate Stop Loss Benefit, the Employer must remit the
amount within 31 days of the date notified by Medical Risk Managers that payment is required.
If the Employer's coverage terminates before the end of the policy period, this benefit will automatically
terminate, and a final reconciliation will be completed.
Medical Risk Managers does a quarterly reconciliation of advance payments. If applicable and once the
reconciliation is completed, a refund will be requested.
Advances are not permitted in the final two months of the policy period.
AGGREGATE CLAIM SUBMISSION REQUIREMENTS
To file a monthly or annual claim, complete the Aggregate Claim Form and submit the required documentation.
Fill in the name and policy number of the Employer group, and the policy period for which the reimbursement
request applies. Indicate the total claims paid amount, minus the aggregate attachment point. Deduct any specific
claim reimbursements, any specific claim denials, any specific claims pending, any benefits paid outside the selffunded plan, and any payment adjustments. The final amount should be the amount of the aggregate
reimbursement request.
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Please include the following documentation:
Paid claims analysis: This form should include the claimant name, first and last date of service, payment
amount, and payment date.
Check Register: The check register provides us with all payments made by the Plan. This report includes
employee name, claimant name, incurred date, amount of payments/voids/refunds, check number, check
date, and payee. This report is compared to the claim listing. The auditor verifies that the check date was
issued and released within the policy period.
Claim listing (also known as the paid claim report): This report provides us with the year to date claim
listing by claimant. The report should include the claimant’s name, date of service, procedure codes,
provider’s name, discounts, non-covered, and paid amount. The auditor verifies that the claims processed
are eligible. Once the report review is complete and the auditor has verified all charges are eligible, the
total amount of the paid claims is compared to what the Plan has reported. Any claims considered “not
covered” are withheld.
Funding Reports for the latest 13 months: This report includes the balance of the account at month’s
end. The auditor verifies that enough funds were deposited to cover the claims paid by the plan within
the policy period. These reports should include deposit tickets, and wire transfer statements.
Eligibility Listing: This report is listed by insured. It includes the insured’s date of hire, effective date of
coverage, dependents, and type of coverage elected. The auditor uses this report to calculate the
attachment point. Without this report we cannot verify the accuracy of the attachment point reported by
the Plan. This report should include employee name, social security number, dependent names, date of
hire, effective date of coverage, active or Cobra status, termination date.
Benefit Analysis: This summary provides us with the type of services and the total amount paid by the
Plan within the policy period such as: prescriptions, surgery, administrative fees, anesthesia, office visit,
dental, etc.
This report should include classification code, benefit type, and total benefit for code.
Rx Billing Summary: This report should include invoice date, amount, pharmacy name, and policyholder
name.
Individual Payment Report: This summary is a listing of all claimants who have exceeded the Stop-Loss
deductible. The auditor calculates each amount in excess of the specific deductible. Once this is complete
the total amount of claims in excess of the specific deductible is deducted from the total paid claims. This
report should include the claimant name, policy period, total claims, and the Specific Stop Loss
Deductible.
Attachment Point Calculation: The Plan reports their Attachment point. This information can also be
found on the loss ratio report. The auditor verifies the attachment point by reviewing the Eligibility report.
Loss Ratio Report: This summary Report provides the employee census, gross monthly paid claims, year
to date gross paid claims, out of contract payments (ineligible payments), specific claim amount, adjusted
monthly paid claims, and year to date aggregate attachment point on a month to month basis.
Please sign and date the Aggregate Claim Form and forward it with the required documentation no later than 60
days after the end of the policy period. For Monthly Aggregate Benefit claims, written request must be made on or
before the 15th day of the month following the month for which the advance is requested.
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AGGREGATE CLAIM REVIEW – DESK AUDIT
The determination of reimbursement due under the Aggregate Benefit will likely depend on an audit on our behalf.
This would include but is not limited to:
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Prior Plan's Extension of Benefits
Employee and Dependent Eligibility
Student Status of Dependents
Pre-existing Conditions
Coordination of Benefits
Subrogation
Worker's Compensation
Any Other Valid and Collectible Insurance
Services Paid Outside the Contract
Verification of Funded Claims
AGGREGATE CLAIM REVIEW - ON-SITE AUDIT
On occasion, Medical Risk Managers will conduct on-site claim audits, whether conducted by MRM employees or
by an outside consultant. The standard documents that should be available at the time of an on-site audit are as
follows:
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


Bank statements for the entire policy period
Enrollment cards
Premium billing statements
Check registers
Claim files
System access for auditor(s)
Prescription card invoices (if applicable)
The on-site Auditor may require additional items as-needed.
REIMBURSEMENTS
Bank wire payments are the recommended method for reimbursement. Please complete and submit the Bank
Wire Form which can be found in the Forms section of this document.
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APPENDIX: ELECTRONIC CLAIM SUBMISSIONS
Medical Risk Managers accepts claim forms and documentation in electronic format. Claim submissions can be
sent via email to [email protected]. Acceptable electronic document formats include:
Document
Word
Excel
Adobe PDF
Text
Scanned images or
screen prints
Examples
.docx
.doc
.xlsx
.xls
.pdf
.txt
.csv
.png
.tiff
.bmp
.jpg
If you intend to submit itemized claim line data using Excel or Text files please ensure the following columns are
included:
Claimant Last Name
Claimant First name
Claimant SSN or identifier
First Date of Service
Last Date of Service
Paid Date
Provider Name
Procedure or Revenue Code
ICD9 Diagnosis Code
Deductible
Copayment
Out of Pocket Cost
Not Covered Amount
Amount Billed
Amount Allowed
Amount Paid
Sample:
Last
First
SSN
First DOS
Last DOS
Date Pd
Provider
Proc
ICD9
Ded
Copay
OOP
Doe
Jane
999-999999
1/3/2012
1/4/2012
2/1/2012
Central
Hospital
99999
414
0
0
0
Not
Covered
0
Amt
Billed
1000
Amt
Allow
800
10
Amt
Paid
800
APPENDIX: CATASTROPHIC CONDITIONS BY DIAGNOSIS
001-139
Infectious and Parasitic Diseases
140-239
Neoplasms
240-279
Endocrine, Nutritional, Metabolic, Immunity
280-289
Diseases of the Blood and Blood-Forming Organs
320-389
Diseases of the Nervous System and Sense Organs
390-459
Diseases of the Circulatory System
460-519
Diseases of the Respiratory System
520-579
Diseases of the Digestive System
630-677
Complications of Pregnancy, Childbirth
710-739
Diseases of the Musculoskeletal System and Connective Tissue
740-759
Congenital Anomalies
760-779
Conditions Originating in the Perinatal Period
780-799
Symptoms, Signs, and Ill-Defined Conditions
800-999
Injury and Poisoning
996 – 997
Complications Peculiar to Certain Specified Conditions
V23
Supervision of High Risk Pregnancy
V42 – V58.9
Transplants and various other procedures
11