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Specific Excess Claims Submissions
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Completed BIG Specific
Reimbursement Request,
Itemized bills and/or proof of loss*,
Re-pricing sheets, if available,
EOB including check number and paid date,
Individual Payment Report (RIP) or other history report,
Enrollment form and any changes,
Evidence of deductible and out-of-pocket coinsurance,
When applicable:
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Large Case Management Reports/Notes
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Pre-cert for any
in-patient admission
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Signed claim form
indicating if other insurance is primary
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Subrogation information
and copy of signed release
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Pre-existing
investigation documentation or certificate of creditable coverage
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COBRA election form and
evidence of premium payment
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Fulltime Student Status
verification
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Confirmation of Work Status/Eligibility Form
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Specific reimbursement requests must be in excess of $100.00.
Please combine your requests whenever possible, and submit them as one
(unless it is the final request). Unless other arrangements are made,
all claims must be fully funded by the employer. Please refer to the
funding requirements below.
*For electronically submitted (EDI) claims, proof of loss is
still required. A copy of the claim printed out in HCFA or UB format is
preferable. For high dollar claims, a paper copy is ALWAYS required. In
lieu of the paper claim for low dollar submissions, if the TPA does not
have a program, which prints a copy of the claim, a VERY detailed claim
report or spreadsheet must be provided. This arrangement must be
pre-approved by Bardon Claims Management Staff.
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EDI Specific Reimbursement Requirements
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The following data must be available on any report or a
combination of reports in lieu of hard copy claims, itemized bills,
repricing data/sheets and EOBs. Please note; all other
reimbursement-filing requirements remain unchanged:
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Date of service for all
procedures
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Place of service
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Diagnosis codes for all
procedures
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Procedure codes whether
CPT, HCPC, or Revenue Codes (for in and out patient procedures)
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Modifiers (affects
anesthesia, multiple surgeries and radiology procedures)
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Amount of discount or
over U&C applied
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Ability to identify if
the provider is PPO or NON
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Co-pays, Deductible and
Coinsurance applied (accumulator screen print is not acceptable as it
is not always reliable due to incorrectly adjusted claims)
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Provider name (preferably
the group and the individual name to verify duplicates)
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Amount paid
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Date paid and check
number
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Copy of pre-certs for
procedures/admissions that require pre-certification
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Claim types that require
a copy of the HCFA or UB and/or itemization
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Inpatient admissions with
billed charges in excess of $20,000
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High dollar multiple
surgery bills (on a case by case basis)
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Bardon reserves the right to request additional
information, including medical records, operative reports, screen
prints or itemized bills as needed, for any claim.
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50% or Potential Claim Notification
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This form should be completed if any of the
follow situations occur:
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An ongoing claim
approaches or has exceeded 50% of the specific deductible.
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There is a potential for
a large claim and the diagnosis appears on Bardon’s
Trigger Diagnosis Codes.
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There is a confinement of
greater than 30 days.
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A confinement is
out-of-network or out-of –the area
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Advance Specific
Requirements
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Subject to all provisions and terms of the American National
Insurance Company (ANICO) treaty, ANICO will advance specific excess
loss reimbursement benefits to the treaty holder to the extent that
such eligible claims exceed the specific deductible. The plan
must have paid the providers to which such eligible claims relate all
amounts equal to the specific deductible shown in the treaty.
Advancements for specific excess loss reimbursements are not available
for amount of less than $1,000.
Incurred claims must be reported and paid before the end of
the contract period.
Specific Advance will cease if the treaty is canceled or
terminated for any reason.
Specific Advance will cease if the treaty holder does not pay
the required premium.
Advancement of funds will only be made to the treaty holder.
Advanced funds may only be used to pay providers for eligible
claims in accordance with the plan.
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Simultaneous Funding Requirements
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Requests must be received within 7 (seven) days of the last
check run.
Each request must exceed 10% of the specific deductible.
Bardon must receive these requests during the contract
period.
Requests in the last 30 days of the contract period require
prior notification and approval by Bardon.
Simultaneous funding is not available once the contract year
has ended.
Simultaneous funds issued to the TPA/Employer must be
deposited immediately upon receipt and all associated checks placed in
the mail simultaneously.
Stop loss premium must be
current for the month in which the request occurs.
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Aggregate Excess Claim Submissions
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1. Detailed claim report prepared/run according to the
contract basis with:
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Incurred dates of service
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Amount charged for
individual claim
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Amount and paid date for
individual claim
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Payee/Provider name
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Claimant name and YTD
totals for each claimant
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2. Check Register; if voids & refunds are not
included provide a separate report,
3. Outstanding un-recovered overpayments,
4. Prescription drug invoices (when applicable)
with administrative fees identified,
5. Monthly census counts (accommodations),
6. Eligibility Listing (final aggregate only) must
include:
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Coverage and benefit types identified,
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Effective and termination
dates for all employees and their dependents eligible during the
contract period in question,
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7. BIG
Aggregate Excess Risk Form, (or TPA equivalent)
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8. TPA Reimbursement Request,
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9. Detail report of specific claims,
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10. Total claims paid outside fund or
ineligible (i.e. exceptions),
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11. Benefit analysis report (amount paid by
benefit code or service type),
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12. Bank Statements, copies of deposits
and/or wire transfers for the entire contract period and the month
following the last month (final aggregate only),
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13. Completed Funding
Questionnaire (final aggregate only).
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Bardon must receive
accommodation requests by the 15th of the month following the
calculation period. Accommodations must be in excess of $1,000.00,
unless it is the final reimbursement.
Accommodations
will not be issued after the 11th month of a 12/12 contract or the 14th
month of a 12/15 contract.
Final aggregate requests should be submitted no
sooner than 30 days after the close of the policy period, including any
run-out.
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Proof of Payment
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Copies of checks or other acceptable claim
payment verification is required for a claim to be considered for
reimbursement. An example of other acceptable claim payment
verification is a computerized explanation of benefits listing check
number, check date, check amount and payee.
In instances where a specific advance reimbursement is requested,
actual claim payment verification is required on all amounts up to the
specific retention only. On amounts over the specific retention, the
date you complete processing the claim is considered the payment
date. Other claim payment verification documents should be
submitted to us for approval.
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No Loss/No Gain
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If the plan is being rewritten in its
entirety (as opposed to amended and restated), or if the plan is in its
initial year of self funding, it is important that a "no loss/no
gain" provision be included in the plan document to facilitate a
smooth transition of coverage for the current plan beneficiaries.
When a claimant was a plan beneficiary under the immediately preceding
plan of benefits and has incurred charges that would be subject to the
"no loss/no gain" provision, it will be necessary to provide
the last monthly billing for the prior plan along with a copy of the
prior plan document or group policy. These items should be provided at
the time the claim is submitted for reimbursement unless they were
provided with the sold case materials.
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Usual, Customary &
Reasonable Charges
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Usual, customary and reasonable (UC&R, R&C)
calculations are required on surgery, assistant surgery, anesthesia,
medical standby, and some consulting services unless otherwise
specified in the plan document.
Most contracts exclude expenses resulting from services which are
billed in excess of the UC&R charge for the locality where
administered or an amount which is in excess of the plan benefits.
When submitting claims that require UC&R review, please submit your
calculations and source (HIAA, MDR ,
etc.) as part of the claim proofs. Maximum reimbursement will be based
on the 90th percentile unless otherwise specified in the plan document.
If UC&R calculations are not provided
for anesthesia or the assistant surgeon, reimbursement for the
anesthesiologist will be limited to a maximum of 30% of the eligible
charge for the surgeon and reimbursement for the assistant surgeon will
be limited to a maximum of 25% of the eligible charge for the surgeon.
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Student Status
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We will consider reimbursement of a claim in
respect to a dependent whose eligibility is based upon full-time
student status only when verification of full-time student status is
received in writing. This verification must be provided by the
institution the dependent is attending, on said institution's
letterhead. The institution must meet the definitions of the plan
document for such institutions. Proof of student eligibility should be
provided with the claim submission.
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