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