Stop Loss Concepts - Managing Underwriters and Program Administrators

Stop Loss Concepts - Aggregate Reimbursement Request Form

Carrier:			Employer:
Policy Number:			Policy Type:
Policy Period:	-
TOTAL CLAIMS PAID DURING THE POLICY PERIOD:
Less Annual Aggregate Attachment Point:
Less Specific Claim Reimbursements Paid (provide details below):
Less Specific Claims Pending (provide details below):
Less Specific Claim Denials:
Less Benefits Paid Outside the Self Funded Plan:
Adjustments (provide explanation below):
AGGREGATE REIMBURSEMENT REQUESTED:

Details of Specific Claims (Paid and Pending)
Name			Date	Total Amount






Other Adjustment Explanation:


The following items are required when submitting a claim (please check items included):
Census Reports by month along with any retroactive census adjustments, including dependents, COBRA, etc.
Large Claim Report (starting at $0)
Refund/Void Report (Effective Date of Policy to Date)
Proper documentation of adequate funding, i.e., bank statement from client (Policy Period)
Check Register
Information and documentation on all outstanding overpayments, subrogation or third-party liability
Claim Benefits Summary (Policy Period)
Claim and EOB for all claims over $5,000
Cancelled Checks for all claim payments over $10,000 and for checks issued the last 2 months of policy period
Lag Report
Detailed report for Rx plan, if applicable
Current Plan Document

Completed By:
				( )
Third Party Administrator		Contact Person		Phone Number

Address		City		State	Zip