MCO Application

MCO Reinsurance Application

 

MCO Name  

Date 

Address

Years in business

 

Counties Served

 

Total Lives at risk now under capitation

 

Total # HMO's

Total lives at risk under proposed new risk contract(s) 

 

Total IPA's 

Number of members for each population:

 

Medicare

 

ED

Medicaid

 

ED

Commercial

 

ED

Other

 

ED

 

Type of risk being taken by HMO / MCO: (check appropriate blanks)

All (Global) risk

Pharmacy

Hospital charges in-area

Home Health/ SKF

Hospital charges out of area

Hem/Onc

Primary Care Professional

Psych

Specialty Care Professional

DME

Professional charges out of area

Transplants

Other 

 

Please check desired Professional and Hospital deductibles

(if pure per diem policy reimbursement desired, so indicate in "B")

 

A) Co Insurance / Deductibles (C=Commercial, M=Medicare, D=Medicaid)

Co Insurance

Physician/Hospital

 80%

 90%

 

Deductibles

Physician

Hospital

 $7,500

 $10,000

 $15,000

 $20,000

Other 

 $30,000

 $75,000

 $40,000

 $100,000

 $50,000

 $150,000

 $60,000

 

Other 

 

B) Per Diem(s)

(Claims Reimbursement @ 100% co ins.)

Option 1

ACU

ICU/CCU/NICU

$700

$1000

$800

$1,100

$900

$1,350

Other

Option 2

 /D in area

 /D OOA

Tplants incl

State Desired Coverage:

Claims Basis: Incurred in 12 months, paid in 18 months basis.

 

 

Fee schedule reimbursement at RBRVS and/or Medicare allowable? Yes No

Other - Claims Bases

Accrued at %

 

Please provide aggregate coverage at % of budget with a 90% co insurance. Yes No

If yes, please attach 3 years claims data by month: i.e. Total claims PAID and # lives covered in each month. Also include actuarial cost/capitation reports.

 

Please provide:

Insolvency coverage: Yes No

Conversion Coverage: Yes No

Inner Aggregate option: Yes No

Copy of current stop-loss Policy: Name: Years:

 

Please provide Name(s) of HMO's/EPO's/PHO's being contracted with (if applicable)

Name

# of years

E.D.

 

Utilization and Control Techniques:

Do you have a full time Medical Director? Yes No

Number of FTE doing QA/UR/UM

Please provide program description for UM.

Name of current Utilization Management software

Name of National PPO Network Provider

 

 

Contact Information & Comments

Contact Name 

Title 

Contact Number 

Additional Comments

 

Please be prepared to provide:

  • Summary of hospital per diem agreements for in network ACU, ICU, CCU, NICU, Burn, Tplant
  • Reinsurance Recovery Report past two years (if applicable)
  • All current claims in excess of 50% of current attachments.
  • Days per 1000 for Medicare, Medicaid, Commercial populations Ave. inpatient charge per day (if available)
  • Audited Financials of HMO (Income statement past 1- 3 years)
  • Audited Financials of Hospital System backing owned HMO
  • Prognosis and Diagnosis of any currently hospitalized patients or members expected to exceed 50% of retention.
  • Broker of record letter authorizing Provider Risk, Inc., Broker of record
  • Census (Age/ sex delineated for current book)
  • Summary Benefit Sheet(s) or Member hand books (Please include 4 copies)
  • Actuarial Analysis (if available)
  • Decription of National PPO network contract inclusive of Transplant, NICU, pharmacy, Burn, cardiac, cancer, rehab if it exist. (i.e. Case rates or perdiem contracts)

 

 

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