MCO Application

Provider Stop Loss Application

 

Name 

Date 

Address

Years in business

 

Counties Served

 

# Physicians in Network , employed ; # Hospitals

 

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 

Max PER DIEM

$2,500 

$3,000 

OOA $

Other

State Desired Coverage:

 

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

Term: Incurred in 12 months, paid in 18 months basis. Yes No

 

 

Fee schedule reimbursement at HCFA GPCI? Yes No

Other fee schedule

Accrued at %

 

Maximum Benefit (Spec) :$250,000 Physician risk and $1,000,000 Hospital risk specific. Yes No

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 copy of current stop loss Policy: Name  yrs

 

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

Name

# of years

Federally Qualified

E.D.

 

 

Yes

No

 

 

Utilization and Control Techniques:

Do you have a full time Medical Director? Yes No

Do you have a full time CIO? Yes No

Do you have a full time CFO? Yes No

Number of FTE doing QA/UR/UM

Do you provide 24 hr call in UR management? Yes No

Please provide flowchart if available.

What package of software are you using to monitor costs?

Name of National PPO Network Provider

 

 

Please provide:

All provider contracts with HMO's contracted

Name of In-Network Hospitals

Perdiems

 

ACU

ICU

NICU

National contracted provider

Reinsurance Recovery Report past two years

Diagnosis & Prognosis of claims excess of 50% retention YTD.

Days per 1000 for Medicare, Commercial populations

Do you adjudicate your claims? Yes No

Describe contracts to deliver care for: Burns, NICU, and Transplants

 

Contact Information & Comments

Contact Name 

Title 

Contact Number 

Additional Comments

 

 

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