Specific Claims

Specific Claim Submission Procedures

Notification of Catastrophic Claim Requirement

Specific Claim Advance Provision

BEST Re Cost Control Claim Service

Specific Claim Submission Procedures

Our Claim Department’s primary goal is to process your claims quickly and accurately. You can help us by including the following material with both new or supplemental specific excess reimbursement and advance requests:

• A BEST Re Specific Coverage Verification and Claims Calculation form, completed and signed

• A copy of Employee’s signed and dated enrollment form and all other information related to the participant’s eligibility or coverage continuation.

• Claim calculation worksheets/explanation of benefits (EOB)

• A detailed claims payment report that includes the following:

  • Claimant name

  • Claimant DOB

  • Provider name

  • Provider tax ID

  • Dates of service (from and through)
    

  • CPT/HCPCS codes for each item being billed

  • ICD-9 codes

  • Charged amount

  • Discount amount

  • Paid amount

  • Date paid

• A copy of the Employee’s completed claim form or similar documentation showing dependent’s employment status or other insurance coverage status

• Copies of any applicable investigation documents, medical records, case management notes, accident reports, subrogation/recovery details, eligibility determinations, and HIPAA certifications or pre-ex investigations.

• Copies of all itemized bills that are greater than $1,000.00.

Notification of Catastrophic Claim Requirement

Written notice must be given to BEST Re when an Individual Specific Claim has reached 50% of the Specific Attachment Point, or immediately upon the Administrator’s notification of a claimant diagnosed with any of the catastrophic medical conditions outlined below, regardless of the Specific Attachment Point or question of coverage. The following diagnosis and/or guidelines represent potential high cost/catastrophic cases for which case management should also be utilized:

• Renal failure

• Major organ transplants (including stem cell or bone marrow)

• Heart surgery

• Diabetes

• Serious burns, (10% of the body with third degree or 20% of the body with second degree burns)

• HIV/AIDS and related conditions

• Serious psychoneurotic impairment

• Multiple or serious fractures

• Eating disorders (anorexia, bulimia)

• Spinal cord injuries

• Premature birth or significant congenital defects

• Chronic medical conditions (requiring long term treatment or rehabilitation)

• Cerebral vascular accidents

• High risk pregnancies

• Head traumas or brain injuries

• Amputations or permanent loss of limb(s)

• Chronic blood disorders

• Cancers

• Neonatal high risk infants

• Crushing or massive internal injuries

• Hospitalizations of more than 15 days and multiple hospital confinements

• Loss of sight or hearing

• Infusion therapies

• All other injuries or sickness which may, in the opinion of the administrator, develop sufficient loss to reach the Specific Deductible

• Specific/Notification Claim Form

Specific Claim Advance Provision

For questions regarding Advance Funding provisions, please contact the BEST Re Claim Office at (208) 893-5049 or email: ldemczuk@bestre.net

BEST Re Cost Control Claim Service

BEST Re offers Cost Control Claim Services with no added monthly cost, but a reduction to the client’s bottom line:

• Claim Re-pricing

• Bill Negotiation

• U & C Audit Review

• Medical Necessity Review

• Specialty Cancer Care Review

• Specialty Dialysis Care Review

The BEST Re Cost Control Claim Service includes access to several national re-pricing vendors. These vendors contract with providers throughout the nation to offer discounts on both out-of-network and in-network claims. BEST Re has attained an average claim savings of 22.5% of billed charges and some claim savings have been as high as 75% of the billed charges. This benefit not only reduces the bottom line for some plans, it has had a positive impact on an employer’s renewal.

Claim Re-pricing for out of network claims will have a turnaround time of 2-3 business days. All facility (UB92) bills need to include the itemization.

Bill Negotiation, Medical Necessity, U&C Audit, Specialty Cancer Care/Dialysis reviews will need to include:

• Itemization and UB92 (facility)

• Operative Report

• Medical Records (on a requested basis only)

• Case Management Report

• Treatment Plan for Cancer Care (chemotherapy)

• Implant invoices as requested

The normal turnaround time is 5 to 7 business days.

All Bill Negotiations will include a copy of the sign-off from the provider. Medical Necessity and U&C Audit reviews will include a sign-off from the provider (if obtained) or instructions of what messages must appear on the Explanation of Benefit statement to the provider and the amount of discount to apply to the bill.  All vendor fees for this service are fully reimbursable under the specific and aggregate coverage’s, and are subject to the normal policy plan/limits.

We encourage you to use these services for all of your group’s eligible (as defined in the plan document) out-of-network claims over $1,000 and in-network claims over $5,000 with discounts of 10% or less. 

Attach the BEST Re Cost Control Claim Form and forward it either by fax to
(208) 893-5040 or email: ldemczuk@bestre.net.

Please mail Claim Forms to:

BEST RE
Attention: Claim Department
2700 West Cherry Lane, Suite 130
Meridian, ID 83642
877.868.5775 business extension 360
(208) 893-5040 fax
email