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Claims
Specific
Claim Submission Procedures
Notification
of Catastrophic Claim Requirement
Specific
Claim Advance Provision
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
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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)
-
Copies of the original claim checks or other specific deductible
fund verification
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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.
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Copies of all itemized bills that are greater than $1,000.00.
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Specific Loss Eligibility Sheet
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Specific Request Form
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
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Neonatal high risk infants
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Crushing or massive internal injuries
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Hospitalizations of more than 15 days and multiple hospital confinements
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Loss of sight or hearing
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Infusion therapies
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All other injuries or sickness which may, in the opinion of the
administrator, develop sufficient loss to reach the Specific Deductible
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Notification
of catastrophic claim form
Specific Claim Advance Provision
Although,
the stop-loss Contract is a reimbursement contract and is not
to be deemed “insurance”, Specific Advance Funding
is a standard feature of every Excess Risk Reimbursement Contract
we issue. However, BEST Re’s policy is to honor specific
advance funding requests on an administrative basis. This administrative
provision is designed to provide the employer with funding assistance
for large claim payments.
When
requesting specific advance funding on behalf of your client,
the administrator must agree to the following terms and conditions:
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The specific deductible must be paid prior to any advance.
-
Checks issued by the Plan, which accumulate towards the employer’s
specific deductible, must be released to the payees prior to requesting
an advance.
-
All claims in excess of the specific deductible, which are submitted
for advance funding, must be identified as such.
-
A list of payments to which the advance applies must be provided
with your request.
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Advanced funds must be paid directly to the provider for which
the advance payment was requested.
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Once the advance is received and claims are paid, the check numbers,
dates and amounts, if not previously provided, must be reported
to BEST Re.
-
It is imperative that administrator checks, which have been issued
for the claims in which the advance request is made, can be verified.
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The Administrator will provide all services and satisfy all reporting
requirements as if the claim has been funded/paid.
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Requests for an advance must be made no later than 30 days after
expiration of the time period specified in the Stop-Loss Contract
for payment of plan benefits.
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Specific Loss
Eligibility Sheet
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Specific Request Form
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