Stop Loss Concepts, Inc. Specific Reimbursement Request

Insurance Carrier:
Initial Claim Continuing Claim

Employer's Name:
Policy Number & Type:
Policy Period
From:
To:
Employee Name:
Claimant's Name
(if other than employee)
 Relationship to Employee

 Original Effective Date of Claimant's
Coverage Under Employer's Plan
Employee Hire Date
 Termination 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: $ is claim for? 1) Workers Compensation:
Less Specific Deductible: $ 2) Subrogation:
Balance: $ 3) Pre-existing:
Reimbursement Request: $  

COMPLETE FOR CONTINUING CLAIM
Plan benefits paid this submission: $
Reimbursement Requested: $

Claim request cannot be processed without the following information:
Investigation Materials/Supporting Documents for:
  • Claimant and Attending Physician's Statement
  • Other Insurance
  • Full Time Students
  • Hospital Audits
  • Pre-existing
  • Hospital Records
  • Enrollment Form
Copy of All:
  • Bills
  • Calculation Sheets
  • Deductible/Coinsurance Proof
  • Medicare Election Form
  • Explanation of Benefits
  • COBRA Election Form
  • R & C Calculations

TPA NAME: CONTACT PERSON:
ADDRESS:
 PHONE NUMBER:
 DATE SUBMITTED:

E-MAIL: