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Specific Reimbursement Claims

The employer's plan document defines the terms of coverage for specific claims reimbursement. The Stop Loss contract defines reimbursements available to the employer for benefits paid according to the self-insured plan document.

Our goal: to reimburse employers as quickly and accurately as possible.

Filing a Specific Stop Loss claim

Notify us as early as possible of potential specific claims.

As soon as paid claims for the contract period exceed the Specific deductible, submit an initial Specific Reimbursement Request with the following:

• Copies of all pertinent eligibility documentation (e.g., enrollment card, screen prints of history, COBRA payments, documentation and verification of creditable coverage (how coverage is maintained while off work)
• Results of other insurance, Medicare and subrogation investigation
• Copies of care certifications (preauthorizations, hospital precertifications, etc.)
• Copies of case management progress notes
• Copies of all provider bills (refunds, benefit exceptions, overpayments)
• Copies of EOBs
• Claim history report
• Proof of deductible and out-of-pocket

Any subsequent claim filings must include:

• Claim history report
• Copies of care certification (preauthorizations, hospital precertifications, etc.)
• Copies of case management progress notes
• Copies of all provider bills (refunds, benefit exceptions, overpayments)
• Copies of EOBs

Claims time service

Our goal is to process Stop Loss specific claims within 10 business days. By "process" we mean:

• Claim fully reviewed
• Initial decision made
• First communication sent to the TPA

At this time, the claim may be:

Action	Description
Paid	TPA receives a check and a letter.
Partial Paid	TPA receives a check for the portion that can be finalized. Letter asks for additional information needed to pay the balance.
Pended	TPA receives a letter that explains why the claim cannot be finalized at this time and lists additional information needed to complete claim processing.
Denied	TPA receives a letter explaining the reason(s) for claim denial.

Appeal of claim denial

To appeal a claim denial, submit a request in writing to our Stop Loss Claims department specifying your reasons for appeal.

Hospital Bill Audits/Evaluations

Any more, it's not enough to only have a PPO discount in place. In addition to that, evaluating such things as unbundling; billing for the appropriate level of care; inappropriately high billed charges; and inappropriate treatments needs to be a part of the claim payment process. If they are not, you will most likely end up reimbursing the claim at a level that is higher than necessary. There are many vendors that can help you. Mutual of Omaha does not require that you use a particular vendor; however, we do ask that you ensure that steps are being taken to facilitate the most cost effective care.

If you would like help in referring a claim for pre-payment audit or negotiation, please contact Carol Tarkowski at (402) 351-5765 or Carol.Tarkowski@mutualofomaha.com.

Subrogation

The following may represent situations with possible subrogation issues:

• Motor vehicle accidents
• Malpractice cases
• Illness or injury induced by a product
• Accidents that occur on property owned by someone other than the claimant

For stop loss reimbursement, we require accident details, a police report (if available), plus information regarding attorney involvement. In cases where there may be subrogation, a third-party vendor represents our interests.

Contact Us

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