Stop Loss Claims

Dedicated claim analysts work directly with you so that we can reimburse employers as quickly and accurately as possible.

Specific Reimbursement Claims

A Specific stop loss claim occurs when an individual's eligible losses paid under a self-insured plan exceed the specific deductible within a benefit period.

Aggregate Reimbursement Claims

Aggregate stop loss claims occur when the sum of all eligible losses within a benefit period, less amounts reimbursed as specific claims, exceed the annual aggregate deductible (also known as the "Aggregate Attachment Point").

Advance funding

Large medical claims can place significant cash-flow burdens on employers. We offer both specific and aggregate accommodation/advance funding features to help prevent employers' cash-flow problems.

• Specific advance funding
  Advance funding riders must be included in the Stop Loss policy in order to request a specific advance/accommodation.
  
  Our goal is to process specific advance funding requests within 10 working days of receipt of all required information, provided: the amount due exceeds $1,000; and, proof of claim processing has been received.
  
  To process an advance funding, we need all the information normally requested for a specific claim.
  
  When we receive a specific claim requesting advance funding we will review it for levels of discounts obtained and to determine whether or not a hospital bill audit/evaluation has taken place
  
  If it appears that there is a potential for a greater discount, or there has not been a hospital bill audit/evaluation we will contact you to discuss this before reimbursing the claim.
  
  
• Aggregate advance funding
  Advance funding riders must be included in the Stop Loss policy in order to request an aggregate advance/accommodation.
  
  We do not monitor claims for monthly accommodations. The TPA must monitor and request reimbursements, when applicable, using the Aggregate Advance Funding Request.
  
  Our goal is to process accommodations within 10 working days of receipt of all required information, provided the amount due exceeds $5,000. Any aggregate reimbursement due will be reduced by previous monthly accommodations paid.
  
  Repayment of any outstanding accommodations must be made within 15 days of the time the contract terminates.
  
  Year-end aggregate claims will be reduced by any previous accommodations paid by Mutual of Omaha.

Contact Us

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