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Aggregate Reimbursement Claims

Calculating aggregate deductibles

You can determine aggregate deductibles by using the following calculations:

Minimum monthly aggregate deductible
= (Initial single employee count x single employee factor) + (initial family count x family factor)

Monthly aggregate deductible (MAD)
Greater of:
Minimum monthly aggregate deductible, or
(Current single employee count x single employee factor) + (Current family count x family factor)

Annual aggregate deductible
= Sum of the monthly aggregate deductible (MAD) for the policy year

Calculate whether an aggregate Stop Loss reimbursement is due

Subtract the following from the total eligible claims for the contract period.

• Ineligible or extra contractual claims
• Refunds/recoveries/voids
• Specific claims (paid or payable)
• Aggregate deductible
• Subrogation recoveries

This result, less any previous aggregate advances, is the amount due the employer.

Aggregate claim process

Submit the aggregate claim to Mutual of Omaha. We require the following basic items to process aggregate claims:

• Monthly aggregate report
• Aggregate reimbursement request
• Detailed paid claims report
• Check register report
• Specific reimbursement breakdown
• Census report

Additionally, we require:

• Copies of all subrogation recoveries that apply to claims paid during the contract year
• A list of all outstanding subrogation claims paid during this contract year, with current status of each claim
• A list of all refunds received in the contract year
• A list of all outstanding refunds for the contract year

Claim Review

Our claim analysts will perform the initial claim review (pre-audit) and, based on the results, may require an in-house or on-site claim evaluation. Every aggregate claim is pre-audited prior to reimbursement.

In-house audit

When appropriate, we perform in-house audits. Our Claim department will request additional information from you to facilitate the audit.

Audit findings will be discussed with you, and the results agreed upon plus a report and check (if due) will be mailed or a follow-up audit scheduled.

On-site audit

When appropriate, we perform on-site audits. Our claim department contacts you to schedule the claim audit at your office.

We provide a list of information required to be available for review.

The findings of the on-site audit will be discussed with you, and the results agreed upon plus a report and check (if due) will be mailed.

Contact Us

For more information about our claim administration or TPA Stop Loss products, submit a request.