Specific Excess Claims Submissions

EDI Specific Reimbursement Requirements

50% or Potential Claim Notification

Advance Specific Requirements

Simultaneous Funding Requirements

Aggregate Excess Claims Submissions

Proof of Payment

No Loss / No Gain

Usual, Customary & Reasonable Charges

Student Status


Specific Excess Claims Submissions

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:

Large Case Management Reports/Notes


Pre-cert for any in-patient admission


Signed claim form indicating if other insurance is primary


Subrogation information and copy of signed release


Pre-existing investigation documentation or certificate of creditable coverage


COBRA election form and evidence of premium payment


Fulltime Student Status verification


Confirmation of Work Status/Eligibility Form

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

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:

Date of service for all procedures

Place of service

Diagnosis codes for all procedures

Procedure codes whether CPT, HCPC, or Revenue Codes (for in and out patient procedures)

Modifiers (affects anesthesia, multiple surgeries and radiology procedures)

Amount of discount or over U&C applied

Ability to identify if the provider is PPO or NON

Co-pays, Deductible and Coinsurance applied (accumulator screen print is not acceptable as it is not always reliable due to incorrectly adjusted claims)

Provider name (preferably the group and the individual name to verify duplicates)

Amount paid

Date paid and check number

Copy of pre-certs for procedures/admissions that require pre-certification

Claim types that require a copy of the HCFA or UB and/or itemization

Inpatient admissions with billed charges in excess of $20,000

High dollar multiple surgery bills (on a case by case basis)

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

This form should be completed  if any of the follow situations occur:


An ongoing claim approaches or has exceeded 50% of the specific deductible.


There is a potential for a large claim and the diagnosis appears on Bardon’s Trigger Diagnosis Codes.


There is a confinement of greater than 30 days.


A confinement is out-of-network or out-of –the area

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Advance Specific Requirements

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

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

1.  Detailed claim report prepared/run according to the contract basis with:

Incurred dates of service


Amount charged for individual claim


Amount and paid date for individual claim


Payee/Provider name


Claimant name and YTD totals for each claimant

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:

Coverage and benefit types identified,


Effective and termination dates for all employees and their dependents eligible during the contract period in question,

7.  BIG Aggregate Excess Risk Form, (or TPA equivalent)

8. TPA Reimbursement Request,

9. Detail report of specific claims,

10. Total claims paid outside fund or ineligible (i.e. exceptions),

11. Benefit analysis report (amount paid by benefit code or service type),

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),

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


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


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


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


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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