Please Note: Forms will not "save" with populated data. Please SCAN COMPLETED and SIGNED form, and return to reinsurance@providerrisk.com.
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
Commercial
Other
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
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
$30,000
$75,000
$40,000
$100,000
$50,000
$150,000
$60,000
Max PER DIEM
$2,500
$3,000
OOA $
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
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)
# 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
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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