100 LaCosta Lane, Suite 120, Daytona Beach, FL 32114
Phone (386) 274-2600 * Fax (386) 274-4111
100 LaCosta Lane, Suite
120, Daytona Beach, FL 32114
Phone (386) 274-2600 * Fax (386) 274-4111
Section 1
|
Third Party
Administration Information
|
| 1.1
|
TPA
Responsibilities |
| 1.2
|
TPA
|
Section 2
|
Stop Loss
Information
|
| 2.1
|
Stop
Loss Carriers |
| 2.2
|
Stop
Loss Products |
| 2.3
|
Coverage
& Contracts |
| 2.4
|
Group Stop Loss |
Section 3
|
Requirements
Information
|
| 3.1
|
Underwriting
Requirements |
| 3.2
|
Sample
RFQ |
| 3.3
|
Managed
Care Questionnaire |
Section 4
|
Sold Case
Information
|
| 4.1
|
Sold
Case Submission Instructions |
| 4.2
|
Plan
Sponsor Disclosure Statement |
| 4.3
|
Premium Submission |
| 4.4
|
Monthly Paid Claims Reports |
| 4.5
|
Late Entrants |
| 4.6
|
Utilization Review and Case Management |
Section 5
|
Sample
Monthly Premium Report Forms
|
|
5.1
|
|
|
5.2
|
|
|
5.3
|
|
|
5.4
|
|
Section 6
|
Premium
Letters
|
| 6.1 |
Sample
Termination Letter |
Section 7
|
Claims
Procedures / Instructions
|
|
7.1
|
|
|
7.2
|
|
|
7.3
|
|
|
7.4
|
|
|
7.5
|
|
|
7.6
|
|
|
7.7
|
|
|
7.8
|
|
|
7.9
|
|
Section 8
|
Sample Claims
Forms
|
|
8.1
|
|
|
8.2
|
|
|
8.3
|
|
|
8.4
|
|
|
8.5
|
|
|
8.6
|
An approved Third Party Administrator has the following responsibilities to EBU:
To keep accurate records which may be reviewed by EBU and to make the records available for review by EBU during normal business hours if the need arises.
To provide prompt payment of premiums by the 1st of each month
To provide monthly aggregate reports by the 20th of each month following the month in which the premium is due (i.e. aggregate report for December 2000 should be received by January 20th)
To notify EBU immediately when aware of a potential specific claim related to the following severe conditions (also to notify EBU if claimant is reasonably expected to reach 50% of specific):
Complications of pregnancy
Premature births
Cerebral vascular accidents (i.e. strokes)
Major head trauma
Spinal cord injuries
Amputations
Paralysis
Loss of eyesight or hearing
Severe burns
Multiple fractures
Prolonged hospital stays for diabetic conditions
AIDS, AIDS related complex, or disorders of the immune system
Organ transplants
Coronary bypass
Hospital stays of seven days or more
Artificial joint or cardiac implant surgery
Malignancy of solid organs, blood, or lymphatic system
Survived cardiac or respiratory arrest
To notify EBU immediately if aware of any lawsuits or complaints that may affect EBU.
To provide notice of an amendment to a client’s Plan Document prior to the effective date of the amendment. EBU reserves the right to adjust rates and factors based on any material change to the benefit plan.
To submit all items listed in Section 4.1 in a timely manner so that the policy can be issued within 90 days of the group’s effective date, as required by the carrier. Please note that claims cannot be processed for payment until the policy requirements have been satisfied, and the policy has been issued, and signed signature pages have been received by our office.
To maintain appropriate, current agent and TPA licenses as required by the carrier and applicable laws, and to provide proof of coverage to EBU
To
maintain Fidelity Coverage and Errors & Omissions Coverage and to
provide proof of coverage to EBU
To get TPA Approval/Agent Appointment, we require the following:
Completed TPA Questionnaire
Copy of TPA license and/or Certification (as required by your state)
Evidence of current Fidelity Bond coverage
Evidence of current Errors & Omissions coverage
Completed Agent Appointment Application
Copy of current Agent license (home state and non-resident, if applicable)
With the TPA Questionnaire, you can either print the blank form, or complete it on-line, then send it to your printer (Portrait mode with margins of .5 on all sides is recommended). Please note - the data you enter will NOT be saved, so if you close the browser window before you print, the data you entered will need to be entered again. The Agent Appointment Application is not set up for on-line completion; however, you can print it (again, Portrait mode with .5 margins on all sides is recommended).
It is necessary that all requested information be provided to allow approval – please feel free to add extra sheets as needed to provide complete answers, and note the checklist of attachments required on the last page of the questionnaire.
If
you keep an up-to-date completed questionnaire on file, you may submit that
instead; however, it will be reviewed to ensure all pertinent topics have been
covered.
Stop
loss protection is provided by a contract between the carrier and the employer
or plan sponsor. The carrier is liable for its performance under the terms of
the contract. The presence or absence of a contract between the carrier and a
reinsurer has absolutely no impact on the legal obligations of the carrier to
the employer. Non-performance by the reinsurer does in no way at all diminish
the liability of the carrier to the employer. Most importantly, non-performance
by the stop loss carrier does not allow the employer or plan sponsor to seek
redress from the carrier’s reinsurer. If the stop loss carrier goes
bankrupt or otherwise fails to pay claims, the employer has no legal right to
secure recoveries from the reinsurer.
Because
of this basic principle of contract law, we share your concerns that the stop
loss carrier be financially secure. We can assure you that EBU will not enter
into an agreement with a company which, in our opinion, does not have the
financial resources or business acumen to be a respected and solid stop loss
carrier. We do endeavor to share the carriers’ financial statements with our
TPA’s and clients.
Let
there be no doubt at all that each of our companies is an excellent carrier
and we are proud to be writing on their behalf. Best’s ratings are available
upon request.
We
hope these facts emphasize the necessity to examine the party with whom one
will enter into a stop loss contract and not be diverted by side issues of
reinsurers behind the stop loss carrier.
We
appreciate your confidence and pledge to continue to do our best to serve the
needs of you and your clients.
Specimen policies for each carrier are available upon request.
EBU
is a creative underwriting facility.
We
offer proposals for the following coverages:
1.
Specific
Only (*)
2.
Specific
and Aggregate Medical Only
3.
Specific
and Aggregate with any of the following covered under the aggregate:
a.
Medical
(Required)
b.
Dental
c.
Weekly
Income (Short Term Disability)
d.
Prescription
Drug Programs
e.
Vision
Our
lifetime maximum coverage ranges from $100,000 to $5,000,000.
Coverage
for cornea, kidney, heart, heart-lung, liver, pancreas, and bone marrow
transplants is included in EBU’s contracts if transplant coverage is
included in the Plan Document.
COMMISSIONS
Commissions
vary by carrier. For commission details, please contact our marketing
department.
The
maximum commission available is 15%.
1.
(*)
Specific Only available for medical coverage including prescription drugs.
Stop
Loss insurance is comprised of two elements:
Specific
Stop Loss
Insurance is designed to protect the plan sponsor from large individual
claims. This dollar amount is called a specific deductible. Once this
deductible is satisfied by an individual, the insurance company reimburses to
the plan sponsor the amount over the deducible.
Aggregate
Stop Loss Insurance limits the plan sponsor’s exposure to a maximum annual
claim liability for all eligible claims submitted. This dollar amount is
called an attachment point. The attachment point will move up or down
according to plan participation during the year, but will never be lower than
the minimum attachment point. The insurance company will reimburse the plan
sponsor at the end of the plan year for the total amount of claims in excess
of the attachment point, minus any specific reimbursements.
EBU
offers Specific and Aggregate coverage. Specific deductibles are available
from $20,000 to $300,000 per individual with a minimum enrollment of 100
covered employees. Some states currently limit the Specific Contract type
and/or deductible, pursuant to their particular statutes. Your EBU underwriter
can answer any questions you might have concerning this.
EBU
issues policies with the following coverage basis:
12/12 Claims
incurred in the Plan year and paid in the Plan year.
15/12 Claims
incurred in the Plan year plus the preceding 3 months and paid in the Plan
year.
24/12 Claims
incurred in the Plan year plus the preceding 12 months and paid in the Plan
year.*
12/15 Claims
incurred in the Plan year and paid in the Plan year plus the following 3
months.
12/18 Claims
incurred in the Plan year and paid in the Plan year plus the following 6
months.
*Applies
to renewal business. Coverage for new business is subject to approval.
EBU
will consider other coverage options upon request.
Specific
premium is based on the following factors:
1.
Age
of Group
2.
Sex
3.
Area/Location
4.
Single/Family
Coverage
5.
Contract
Type
6.
Industry
7.
Schedule
of Benefits
Aggregate attachment factors are calculated on the actual experience for the group and the plan of benefits requested. A minimum of two years of claims paid experience by line of is needed, as well as the monthly enrollments.
** Industries currently on the Decline List (updates are made periodically, please check back, and if you have any questions about specific SIC codes that may or may not fall under one of these categories, please contact our office for clarification)
| Associations |
| Casinos |
| Indian Tribes |
| Employee Leasing Firms |
| Multiple Employer Welfare Associations |
| Professional Employee Organizations |
| Long Haul Trucking |
| Hospital Consortiums |
EBU,
Inc. needs the following information to issue a proposal:
1.
Account name
2. Address (including City, State & Zip) - If there are additional locations, the address and number of employees of each additional location should be included
3.
Industry,
nature of business (please supply SIC code, if possible)
4.
Date the quote
is needed
5.
Requested
effective date
6.
A complete
census, including:
a.
Name and Job
Title
b.
Date of Birth
c.
Sex
d.
Single/family
coverage
e.
Life amounts
(if life quote is requested)
f.
Indicate
retirees, if any
g.
Indicate COBRA
participants, if any (health status requested)
7.
Employer
contributions (% contributed for Employees/Dependents)
8.
Name of
administrator, if currently self-funded
9.
Name of
current carrier & effective date of coverage
10.
Name
of prior carrier (minimum of 3 year history required)
11.
Current
benefits and proposed benefits (Plan Document should be included if available)
12.
Current
and renewal rates
13.
Claims
experience (paid claims by line of coverage, time period of experience,
average # employees, benefits included)
14.
Shock
loss information (experience year, amount of claim, name, diagnosis, prognosis
and current status)
We
include a Quote Request Form and a
Managed Care Questionnaire in this manual.
Please use our forms to expedite the proposal request process.
Disclosure of disabled participants, potentially large claims and
claims in excess of 50% of deductible (or reasonably expected to reach 50%
based on diagnosis and/or prognosis) is
required by EBU, Inc. upon sale of proposal.
To: _________________________________ Date: _____________________
Fr: ____________________________________
Re: Managed Care Mini Questionnaire
For: __________________________ Zip Codes: ______________________
Here is a mini questionnaire that can be copied and used for each network needing evaluation. Please note the name of the network and if discounts vary greatly from one area to the next, include the 1st three digits of the zip code(s) involved for this evaluation.
Negotiated
Discount
Per Diem
Hospital -
Inpatient
1. Average Charge / Day N/A $________ - Medical / Surg
$________ - ICU
$________ - Obstetrics
$________ - Mental / Nerv
2. Discount _______% N/A
3. Average Length of Stay _______ ________
4. Utilization _______ ________
5. Outliers - negotiated Yes / No Yes / No
Office Visit
1. Discount _______% N/A
2. Utilization _______ N/A
Psychotherapy
1. Average Charge / Day N/A $________ - Per Visit
2. Discount _______% N/A
3. Utilization _______ N/A
Drugs
1. Discount _______% N/A
2. Utilization _______ N/A
Other Discounts
1. X-Ray and Lab Discount _______% N/A
2. Surgeon Services Discount _______% N/A
3. Hospital Outpatient Services Discount _______% N/A
4. Anesthesia Discount _______% N/A
5. Other Services Discount _______% N/A
Our
carriers require that we issue policies on groups within 90 days of the
effective date of coverage. Therefore,
for a proposal to be considered “sold”, the following information needs to
be submitted within the listed time frames of the effective date:
10 days
Completed Stop Loss Application (and Life Application, if applicable)
Plan Sponsor Disclosure statement
Deposit Premium (Please make checks payable to Monumental Life Insurance or Presidential Life Insurance as appropriate)
Copy of Signing Agent’s current license and Application
for Appointment
(Home state license, and non-resident license, if applicable) (See
Section 1.2 for instructions)
Completed TPA Questionnaire, including attachments (See Section 1.2 for instructions)
30 days
Final Enrollment Census (As of effective date)
Claims Experience to effective date
Qualifications requested on quote
60 days
Plan Document
Prompt
submission of these requirements will expedite contract issuance.
The Stop Loss Policy will not be issued until receipt of all above items, nor can claims be processed and paid until the Stop Loss Policy has been issued, and the appropriate signature pages have been signed, witnessed, and then returned to and received by our office.
Disclosure of disabled participants, potentially large claims and
claims in excess of 50% of deductible (or reasonably expected to reach 50%
based on diagnosis and/or prognosis) is
required by EBU, Inc. upon sale of proposal.
The
monthly premium is due on the first day of each month, and the contract provides
for a 31-day grace period. If the premium payment is not received by the end of
the grace period, the policy can be considered “lapsed” retroactive to the
last day of the month for which premium has been paid.
Reinstatement
of the lapsed policy will be considered only once, and at the sole
discretion of the issuing Carrier.
Please
remit premium using our premium report
forms, or you may use your own reporting
format once it has been approved by EBU.
The
Monthly Paid Aggregate Report must be submitted by the 20th of the
following month for which claims are being reported (August claims should be
reported by September 20). Please complete EBU’s form. Report only claims
which are covered under the policy and remember to subtract void checks,
refunds, ineligible claims, and specific reimbursements.
Late
entrant underwriting prior to contract issue is the responsibility of the Third
Party Administrator. All late entrants prior to contract issued must be reviewed
by EBU. However, after the contract has been issued, late entrant underwriting
shall be done at the sole discretion of the Third Party Administrator.
Utilization
Review (UR) and Medical Case Management (MCM) is required for all of EBU’s business.
Utilization
Review is
defined as the procedure by which the company provides certification for those
admissions that require an in-patient confinement based on medical necessity.
(Also known as Pre-certification)
Concurrent
Review monitors
the continued need for an in-patient confinement in an acute care setting.
Medical
Case Management works
with Utilization Review to identify cases with the potential for high claims
cost and assures that quality, cost-effective care is provided on a timely
basis. Medical Case Management also includes Discharge Planning.
An
approved UR company must meet the following criteria:
1.
Must
have the ability to identify a potentially large claim by the patient diagnosis
and length of stay.
2.
Must
provide immediate notification via fax of any potential large claim.
3.
Must
provide a weekly open case report, which includes the following group/patient
information: Diagnosis, Length of Stay, Procedure(s), Home Care, and Out-Patient
Therapy Treatment (such as Chemotherapy, Radiation Therapy, or Dialysis).
4.
Must
notify the Carrier of any hospital stay, which exceeds seven (7) days.
5.
Must
communicate and furnish reports on an on-going basis with EBU’s MCM contact.
6.
Must
work effectively with EBU’s MCM contact.
[Today’s
Date]
[Benefits
Director at Client’s office]
[Name
of Client]
[Client’s
address]
RE:
[Type of] Coverage
Dear
[
],
This
is to inform you that Contract # [
] has been terminated due to nonpayment of premium as of [last day
coverage was effective]. Any claims incurred after this date will not be
considered for payment.
Sincerely,
Premium
Accounting
cc:
[TPA]
[Carrier]
We
consider notification of claims that are at 50% of retention and potentially
catastrophic claims to be an integral function of the TPA.
Immediate
notification when you become aware of a potential catastrophic claim will help
to implement EBU’s Medical Case Management (MCM) program. All quotes issued
require Utilization review and Large Case Management. In order for EBU’s MCM
program to be effective, EBU needs to be involved at the beginning of the
catastrophic claim.
Please
fax our Advance Notice Of Catastrophic Claim form to our claims
department at the earliest indication of one of the following conditions:
1.
Complications
of pregnancy
2.
Premature
Births
3.
Cerebral
vascular accidents (i.e. strokes)
4.
Major Head
Trauma
5.
Spinal cord
injuries
6.
Amputations
7.
Paralysis
8.
Loss of
eyesight or hearing
9.
Severe burns
10.
Multiple Fractures
11.
Prolonged hospital stays for diabetic conditions
12.
AIDS, AIDS related complex, or disorders of the immune system
13.
Organ Transplants
14.
Coronary bypass
15.
Hospital stays of seven days or more
16.
Artificial joint or cardiac implant surgery
17.
Malignancy of solid organ(s), blood, or lymphatic system
18.
Survived cardiac or respiratory arrest
It
is essential that all available information be reported. Please answer all
questions completely.
The
same form should be filed as notice for claims that have reached 50% of the
Specific Deductible. Even if you have provided EBU with an advance notice of a
potential claim, please notify EBU when the claim reaches 50% of the Specific
Deductible.
Please
submit the following:
1.
Complete
the Request For Specific Reimbursement form in full.
2.
Complete
the Claim Worksheet.
3.
Provide
the following additional information:
a.
Copy
of actual enrollment card reflection the initial effective/hire date
b.
Patient
claim form and attending physician’s statement(s)
c.
Legible
copies of completed Claim Worksheet(s)
d.
Legible
copies of claim drafts showing payment(s) issued
e.
Legible
copies of all supporting bills to be considered
f.
Legible
copies of all investigative correspondence
g.
COBRA
election form and proof of premium payment if applicable.
h.
Signed
subrogation letter and police report
i.
Pre-Certification
documentation
j.
Proof of
applied deductible and out-of-pocket prior to this policy year
Specific
claims will be reimbursed according to the plan document benefits and
provisions, payment accuracy, investigative results and claimant eligibility. If
an investigation was conducted we will require a copy of all correspondence and
responses.
Claimant
eligibility will be based on student status, underwriting disclosure, COBRA
participation and employment status.
On claims that involve a third party we will require accident details, police report, other insurance information, a signed subrogation agreement, and the name and phone number of the claimant’s attorney. This information will be forwarded to the carrier for further review.
In
an endeavor to achieve greater claims savings we request that alternative cost
control methods be used in lieu of hospital audits. It is preferred that a
discount be negotiated with the facilities. This negotiation can be performed by
a qualified member of your staff, or by an outside vendor. If you are unable to
negotiate with the provider, or if a substantial savings cannot be realized from
a discount, we request that the bill be sent to a professional bill review
company. Our Claims Department can provide the names of firms that provide line
item analysis and re-pricing.
All
hospital bills should be analyzed for excessiveness considering the diagnosis,
length of stay and the treatment rendered. Bills considered immoderate should be
referred to a professional bill review company.
It is expected that all hospital bills exceeding $20,000, or that appear to be excessive, have some cost savings procedure implemented. It is recommended that 10% of the bill be pended until an audit can be arranged. Ten percent would remain pended until the audit results have been provided.
Complete
the Aggregate Reimbursement Request form:
The
completed Aggregate Reimbursement Request should be submitted to our Claims
Department, along with:
Þ
A
detailed paid claims report reflecting claims paid for each individual claimant,
incurred and paid dates, and service and diagnosis codes.
Þ
An
eligibility listing showing the original effective dates with the plan,
termination dates, COBRA participants, dependent names and dates of birth.
Þ
Check
registers by month for the policy period.
Þ
Proof of
funding of the final check register.
Þ
Copies of
COBRA election forms and proof of payments for all COBRA participants with
claims paid included in this request.
Upon
receipt of the claim and supporting documentation, a review will be made by our
Claims Department to determine if an on-site audit will be necessary. If one is
required, you will be contacted regarding the scheduling of the audit. At that
time, you will be provided with a list of claims to be audited and any
additional materials that will be necessary.
We will make every attempt to schedule on-site audits within thirty days of receipt of the Aggregate reimbursement request.
Complete
the Monthly Paid Aggregate Reimbursement Request form:
The
completed Monthly Paid Aggregate Reimbursement Request form should be submitted
to our Claims Department along with:
Þ
An
eligibility listing showing the original effective dates with the plan,
termination dates, COBRA participants, dependent names and dates of birth.
Þ
A Paid
Claims report for the period being reported.
Once
an MPA claim is paid, it will be necessary to file every month until the end of
the policy period or until all reimbursements have been refunded.
With subsequent filings, you need only furnish claims paid reports for
the succeeding months. The final
claim will be handled as an Aggregate Claim. You will need to provide:
Þ
A Paid
Claims report for the policy period summarized by claimant.
Þ
An
updated eligibility listing.
Þ
Check
registers by month for the policy period.
Þ
Proof of
funding of the final check register.
Þ
Copies of
COBRA election forms and proof of payments for all COBRA participants with
claims paid including this request.
Claims
paid outside the provisions of the Plan Document will not be reimbursable under
the specific or aggregate stop loss coverage without prior approval.
Requests
must be in writing. Provide the Claimant and Group name. Summarize the claim
situation and state the out-of -plan proposal. Include the reasoning for the
action, medical necessity and cost savings to the plan. It is important to
include the exact cost amounts, proposed frequency and duration of treatment.
EBU
will request Carrier Review and will submit the carrier’s response in writing.
Claims
paid outside the payment terms of the stop loss policy will not be reimbursable
under the specific or aggregate stop loss coverage without prior approval.
Requests must be made in writing and dated by the end of the policy year or the
run-out period. Provide the name of the claimant and the group. Furnish the
exact dollar amount of the pended charge, the name of the provider and the
reason the charge has been pended.
Requests
will be reviewed promptly and responses will be made in writing.
Our
Claims Department should be notified of claims that have been denied as a result
of ineligibility or plan document provisions. We need to be notified only if the
amount denied exceeds the specific deductible.
Your
report should include the claimant and group name, the amount denied, dates of
service and the reason for the denial.
Site Updated June 2009
Disclaimer