Stop Loss Concepts - Specific Reimbursement Request Form
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Enter Information Below - Click Submit Form When Complete
Claim Type:
Initial
Continuing
Carrier:
Policy Number & Type:
Employer:
Employee:
Policy Period:
-
Claimant:
Relationship:
Hire Date:
Termination DateTermination:
Original Effective Date:
COBRA Effective Date:
ESTIMATE OF FUTURE POTENTIAL LIABILITY (Must Be Completed for every Claim):
$
The Following
MUST
be completed for every claim:
Diagnosis:
Date Claim Incurred:
Total Benefits Paid:
$
Less Specific Deductible:
$
Balance:
$
Reimbursement Request:
$
Lifetime Maximum to Date:
$
COMPLETE FOR CONTINUING CLAIM
Plan benefits paid for this submission:
$
Reimbursement Requested:
$
The following items are required when submitting a claim (please check items included):
Original signed and dated enrollment form
Plan Document/Amendments
Other Coverage Information
Verification of deductible/out of pocket
Student status from bursar's office
Copies of all bills and explanations of benefits
COBRA Election Form/documentation of payments
Pre-existing information
Medicare Election Form
Pre-certification documentation
FMLA/COBRA memo, if claim is for employee
Letter of medical necessity for physical therapy, speech therapy, etc
Credible Coverage, if applicable
Injury Claims: history of accident and subrogation
Home Health Care: copy of treatment plan documentation
Operative report, if assistant surgeon used
TPA Name:
Contact Person:
Email:
Address:
Phone:
Fax:
