Third Party Administrator Questionnaire

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PART I - Entity, Location, Ownership, Affiliation

1.   Name of Entity
2. Address
City   State   ZIP
Phone   Fax
3. Tax ID #
Type of Business: Corporation Partnership Sole Proprietor Sub-Chapter S Corp
4. List of Officers: (Attach additional list if necessary. Submit resumes of Officers, Directors and Owners)
President  Secretary
Vice Pres. Treasurer
5. Please list other companies with whom you have a financial interest (i.e. Insurance companies, PPOs,
HMOs, MGUs, Brokerage operations, etc.)
6. In the last five years, has your business entity ever been involved in a merger? YES   NO
If yes, please describe: 
7. In the last five years, has your business entity ever had a change in ownership? YES   NO
If yes, please describe: 
8. Has your business entity had a change of name, and/or used a d.b.a. or is it operating under an
assumed name? YES   NO
If yes, previous name was:
9. Branch Offices:
Name of Contact
Address
City   State   ZIP
Phone   Fax
Name of Contact
Address
City   State   ZIP
Phone   Fax
10. How do you produce business (clients): (check all those that apply)
TPA Staff Direct
Independent Brokers/Agents
Other, define 
11. If you use independent brokers/agents to produce business, is their compensation for service paid by:
Client directly
TPA
Other, describe
12. If you compensate brokers/agents, or other service providers for business development,
do you disclose to client the amount of compensation paid? YES   NO
13. When do you disclose fees, compensation, etc. to client (check all that apply)?
In initial proposal
In service agreement
At time of 5500 filing
Other, explain

PART II - Systems - Administration And Claims (Hardware and Software)

Administration

Claims
1. Is system on-line or manual?

2. Name of software system
3. Who developed?
4. Year of development
5. Is software leased, timeshared, or owned?
6. If owned, year purchased
7. Name of hardware
8. Is hardware leased, timeshared, or owned?
9. Have you changed/upgraded systems within 
12 months? If yes, please describe:
A. Administration
B. Claims

PART III - Administrative Services (Financial, Eligibility, and Premium Accounting)

1. Staff: Total number of employees in department 
Name/Job Title of Key Personnel and Managers

Yrs. Experience

Yrs. w/Current Employer


If necessary, list additional names on a separate page, and attach. Please include resumes.
2. May clients have system access in their offices?   YES   NO
If yes, which administrative functions can the client perform?
3. Can you provide census and premium funding data electronically?   YES   NO
4. System(s) Security and Audit Procedures:
A. Describe security for master file (i.e. who can enter new groups, changes)
B. Describe security for client funds
C. Describe record retention program for enrollment cards, billing files, etc.
D. Describe back-up system in the event that the computer master file is destroyed.
5. Does your system calculate individual or group premium for fully insured plans, or calculate levels
of funding for self-funded plans?  YES   NO
Or, are they manually calculated and entered in the master file?  YES   NO
6. Describe procedures for adding, deleting and changing Plan Participants and their benefits.
7. What is your philosophy in serving a client's interest if the client asks you to accelerate claim
payments in the last quarter or month of the plan year end?
8. Do you perform bank account reconciliations on Client Accounts?  YES   NO
If no, why not?
9. How often do you generate premium billings for insurance coverage?
On what days?
10. When are premium reminder notices sent?
11. For non-payment of excess/stop loss premiums, when are lapse notices sent?
12. On what date(s) are premium payments run for insurers and excess insurers?
Notes / Comments

PART IV - Claims Administration

1. Staff: Total number of employees in: Adjudication Support Managers
Name/Job Title of Key Personnel and Managers

Yrs. Experience

Yrs. w/Current Employer

If necessary, list additional names on a separate page, and attach. Please include resumes.
2. How many terminals are in use?
3. Is eligibility determined on-line? YES   NO
4. How long is claim history maintained on-line?
5. Has the department been audited by a third party for accuracy/security? YES   NO
If yes, how recently, and give the name of the audit firm:
And type of audit: (check all that apply)
CPA/5500
CPA/Performance
Carrier/MGU
Independent Claims Audit
6. Can you provide claims data electronically? YES   NO
7. Claims are largely (i.e. +75%)
A) processed .................................................... Manually On-Line
B) filed.............................................................. By family By day batch
8. What does a claim represent? (check one)
line item
check
E.O.B.
Other (define) 
9. Based on the above definition, average number of claims processed per hour is
10. What is your payment accuracy objective?
A) Statistical: Number of claims paid
B) Financial: Dollar amount paid without error
11. Describe the payment authority limitation for the claims staff and the criteria for internal audits.
12. What is your payment accuracy performance during the last twelve months?
13. What is your turnaround objective?
14. What is your average turnaround time over the last twelve months?
15. Surgical R & C is based upon: (check primary source)
HIAA
Internal
MDR
Med-Index
Other
If other, please describe:
Surgical: 
Medical: 
Dental:   
16. Is your R & C database on-line?  YES   NO
17. How often is R & C data updated?
18. Are ICD-9 codes captured? YES   NO
19. Are CPT codes captured? YES   NO
20. For what period of time are hard copy claims files retained?
21. Are separate bank accounts maintained for each client?  YES   NO
a) What is included in each account?
b) Who has disbursement authority? 
c) Is there a trust established for Funded Plans?    YES   NO
Describe a "Typical" client funds transaction through your office
22. Do you subcontract any data processing activities?  YES   NO
If yes, please specify:
23. Do you utilize off-site or home claim processors?  YES   NO
If yes, please specify:
24. Describe your procedures for professional Medical and Dental claims review:
25. Describe your procedures for auditing and/or negotiating provider bills:
26. Describe your procedures for using Large Case Management (LCM):
27. Describe the Managed Care Procedures you are using:

PART V - Carriers (Insurers)

1. Please list the excess/stop-loss insurers (carriers) with which you have business:
Carrier Name

# of Cases

# of Lives

 Est. Annual Premium $$

2. Has any carrier terminated their relationship with you in the last 5 years?  YES   NO
If yes, who and why

PART VI - Compliance/Legal/License

1. Describe any previous or pending material lawsuits in the last 10 years:
2. Have any of the principals in your firm or any of your employees (former or current), ever been
indicted or convicted of mishandling/misappropriating any insurance company or client funds?
YES   NO     If yes, please give details:
3. Describe your current procedures for handling client or insured complaints and State Insurance
Department complaints.
4. Has the company (TPA) or its principals ever been adjudged bankrupt?   YES   NO
If yes, please explain:
5. Have you been involved in an audit by the Department of Labor (DOL)?   YES   NO
If yes, please give details:
6. If your operating jurisdiction(s) require(s) licensing,
are you licensed as a/an:

List States/License Numbers
Third Party Administrator
Managing General Agent
Agent
Broker
Other, define 
Please provide a copy of current license(s) listed above.
7. How are you kept informed of changing legal requirements within your market area?
How do you inform your clients of these changes?
8. What membership(s) do you hold in professional and trade associations? (check all that apply)
SIIA SPBA RIMS IFEBP HIRA NALU
NAHU Other (please list) 

PART VII - Insurance/Bonding

1. Do you carry an Errors & Omissions Policy?  YES   NO
If yes, who is the carrier? 
What is the expiration date of the policy? 
What are the limits of coverage for the policy? 
What is the deductible? 
Is contract a claims made policy?  YES   NO

 

2. Do you carry a Comprehensive Liability Policy?  YES   NO
If yes, who is the carrier? 
What is the expiration date of the policy? 
What are the limits of coverage for the policy? 
What is the deductible? 

3. Do you carry a Professional Liability Policy for UR and/or other services?  YES   NO
If yes, who is the carrier? 
What is the expiration date of the policy? 
What are the limits of coverage for the policy? 
What is the deductible? 

4. Do you carry a Fidelity Bond?  YES   NO
If yes, who is the carrier? 
What is the expiration date of the policy? 
What are the limits of coverage for the policy? 
What is the deductible? 
What is the total annual aggregate funds handled for all clients? 

5. Do you require employee bonding?   YES   NO
If yes, which employees? 

6. Have claims been made against any of these policies in the last two years?   YES   NO
If yes, please provide details? 

PART VIII - Financial

1. May we conduct an initial and ongoing financial review of your organization and/or principals using
an independent agency, such as Equifax or Dun & Bradstreet?     YES   NO
If no, why not?  


2. Principal Banking relationship (to be used as a reference):
Name of Bank 
Address
Telephone
Contact  Contact Title 

PART IX - Attachments

1. Please use this checklist and provide the following attachments. If any of these items cannot be
provided, please explain:
Resumes of Officers, Directors, Owners and Key Personnel
Copy of each policy: Errors & Omissions, Professional Liability, and/or Bond, now in effect
If applicable, Last Two Fiscal Year Income Statements and Balance Sheets
Copy of TPA, MGU, Agency, Broker, and Agent License for each applicable state
Marketing Proposal
Marketing Brochure
Sales Literature on PPO and Managed Care
Service Agreement (sample of standard agreement used)
Premium Account Flowchart/Description
Claim Account Flowchart/Description
Sample Billing
Disclosure Form (P.T.E. 77-9)
Evidence of Good Health Form
Samples of Administrative Services Reports available to insurers and/or reinsurers
Samples of Claims Reports available to insurers and/or reinsurers
Sample Plan Document

 

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I certify that the information on this application is accurate to the best of my knowledge and belief. I also understand that a routine inquiry may be made of any or all of the individuals and firms noted herein as
references.
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