Please Note: When making an inquiry, make certain you have the correct policy number.

1. Monthly Census/Claims Report

   The Monthly Census/Claims Report reflects the number of employees as well as claims paid throughout the policy period.

   The Census data represents the number of employees at the beginning of each month while the claims data represents the claims paid for coverages under the Stop Loss Contract.

   Please remit this form within 15 days after the close of the reporting month to:
   

   STOP-LOSS CONCEPTS, INC. 5854 Heritage Landing Drive EAST SYRACUSE, NY 13057 PHONE (315) 449-3406 FAX (315) 449-1921

2. Preliminary 50% Notification of Potential Stop Loss Claims

   Our carriers must be notified of any on-going claim that has already reached 50% of the specific Stop Loss deductible, or has the potential to exceed the deductible, by completing the 50% notification form.

   Refer to the reverse side of the 50% notification form for a list of possible claim characteristics, illnesses, injuries and therapies that (based on experience) are likely to result in a large claim. We ask that this form be completed on any claimant who falls into these categories, even if the claims are well below the 50% threshold. Be as specific as possible when describing the diagnosis and prognosis of each claimant. Follow-up reports on claimants meeting the reporting criteria should be continued on monthly intervals as claims continue.

   Send Completed Form To:
   

   STOP-LOSS CONCEPTS, INC. 5854 Heritage Landing Drive EAST SYRACUSE, NY 13057 PHONE (315) 449-3406 FAX (315) 449-1921

3. Specific Stop Loss Request For Reimbursement:

   In order to assure prompt reimbursement of claims paid in excess of the specific deductible, it is essential that all required information be included when the request is first submitted.

   If an employee's or covered dependent's claim exceeds the specific deductible, complete a specific Stop Loss Reimbursement form.

   Claim Requests cannot be processed without the following information:

   1. Bills
   2. Calculation Sheets
   3. Explanation of Benefits
   4. Deductible/Coinsurance Proof
   5. Medicare Election Form
   6. COBRA Election Form
   7. R&C Calculations
   8. Enrollment Form
   9. Copies of cancelled checks over $10,000 or copies of checks issued in the last month of the policy period

   It is very important that the reverse side of the request form be completed in full.

   Send form with all documentation to:
   

   STOP-LOSS CONCEPTS, INC. 5854 Heritage Landing Drive EAST SYRACUSE, NY 13057 PHONE (315) 449-3406 FAX (315) 449-1921

4. Aggregate Stop Loss Request for Reimbursement:

   When a Policyholder has exceeded the Aggregate attachment point, at the end of a Policy Period, complete an Aggregate Stop Loss Request for Reimbursement Form.

   Send Completed Form to:
   

   STOP-LOSS CONCEPTS, INC. 5854 Heritage Landing Drive EAST SYRACUSE, NY 13057

An initial supply of forms has been included with this manual. Additional forms can be obtained by copying or requesting them from: