Group Name:

Policy Eff Date:

Policy Number:

Claim is through:

# Single:

X

Single Factor: $

=

$

(1)

# Family:

X

Family Factor: $

=

$

(2)

Attachment Point through Month Filed

=

$

(A)

(A) Use total counts times the factors to get (1) & (2), then sum (1) & (2) to get the actual attachment point (A).

Minimum Attachment Point through Month Filed

=

$

(B)

(B) Divide Minimum Attachment Point (listed on the policy) by 12 to get a monthly minimum. Multiply the monthly minimum by the number of months reported to get the Minimum Attachment Point through Month Filed (B)

Total Paid Claims (include run-in, if applicable)

$

(3)

Ineligible Claims

$

(4)

Specific Claims

$

(5)

Net Paid Claims = (3) - (4) - (5)

$

(6)

List the greater of (A) or (B) from table above

$

(7)

Subtotal (6) – (7)

$

(8)

Previous Payments (Any amounts previously advanced and not repaid)

$

(9)

MPA Reimbursement Due (8) – (9)

$

(10)

SPECIFIC CLAIMANT

AMOUNT OVER SPECIFIC

$

$

$

$

Prepared by:

Date:

TPA Name:

TPA Address:

TPA Phone:

TPA Fax: