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Provider Excess Stop Loss

Application Notes

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Application (PDF) files
GENERAL INFORMATION 
Name of Medical Group 
Address
City 
State 
Zip code    
Telephone Number
Fax Number
Contact, Title
Name of Hospital 
COVERAGE DESIRED
Requested Effective Date:
Address
City
 State
Zip code
Physicians Deductible:
Hospital  Deductible:
Co-Insurance:
Hospital  Physicians Both Other
$7,500 $10,000 $15,000
$30,000 $50,000 $75,000
80% 90% 100%
MAXIMUM ELIGIBLE EXPENSE
Physicians Options:

RBRVS
McGraw Hill
CRVS
Other

(Be sure to Include Conversion Factors)
Hospital Options:
 

Per Diem: $

 Med/Surg $ NICU/CCU/ICU $ Transitional Care

Or Average Per Diem: 

$

Or Percentage of Charges:

%
COVERAGE TO INCLUDE (physicians only)
Capitated Primary Physicians
Non-Capitated Contracted Primary Physician
Capitated Specialty Physicians
Non-Capitated Contracted Specialty Physicians
Please provide the following information regarding the capitation contracts you have with various Managed Care Organizations. Use the back of this form or attach additional sheets as necessary.
CAPITATION CONTRACTS
HMO
Street Address
City
State
 Zip

Effective date
Commercial:
Medicare:
Medicaid:
POS:
ENROLLMENT
Current enrollment as of:
MEMBERS
 
  HMO #1 HMO #2 HMO #3 HMO #4
Commercial
POS
Medicare
Medicaid

Member months for the annual period
from: to:
MEMBERS
Current Year:
 
HMO #1 HMO #2 HMO #3 HMO #4
Commercial
POS
Medicare
Medicaid
MEMBERS
Previous Year:
HMO #1 HMO #2 HMO #3 HMO #4
Commercial
POS
Medicare
Medicaid
MEMBERS
Two Years Ago:
 
HMO #1 HMO #2 HMO #3 HMO #4
Commercial
POS
Medicare
Medicaid
MEMBERS
Projected for Next Year:
HMO #1 HMO #2 HMO #3 HMO #4
Commercial
POS
Medicare
Medicaid
Bed days per thousand:
 
Commercial  Medicare Medicaid

PROVIDER INFORMATION
 

NUMBER UNDER
CONTRACT TO YOU

DO THEY SHARE IN
FINANCIAL RISK

NUMBER THAT ARE
CAPITATED

NUMBER OF MEMBERS CAPITATED
Physicians - Primary care
Physicians - Specialty Care
Hospitals
Anesthesiologists
Oncologists
Cardiologists
Neonatologists

PHYSICIANS ONLY List contracted specialties and their arrangements
 
Cardiologists
Neonatologists
Oncologists
Anesthesiologists
Neurologists
  List any other specialists with special arrangements.
 
HOSPITALS ONLY List contracted hospitals with their per diem or discount arrangements. Include outlier (stop-loss) arrangements, if any.
 

NAME

NAME CARDIAC

MED./SURG.

ICU

NICU
  If there are any special arrangements for Trauma, Burn, Transplants, Oncology, Neurology, or Level 4 NICU, please provide data:
 
UTILIZATION AND CONTROL PROCEDURES

Please provide details on utilization review procedures are large case management arrangements used by your facility/organization to control costs. 
Control over utilization:
Prevent excess length of hospital in-patient stays:
Assure quality medical service to members:
Provide meaningful peer review:
STOP-LOSS EXPERIENCE

Please provide the following information on the current reinsurance arrangement(s) you have in your current capitation contracts.
Complete for each different reinsurance arrangement in force. Use back of form or attach separate sheets as needed
Name of Present Carrier
Deductible: $ Co-insurance: %
Current Contract Period
Maximum Benefits: $ Rates: $ Per member per month
Current Coverage SUBMIT A COPY OF THIS COVERAGE WITH THIS FORM
 

The information contained in this request and transmitted with it constitutes the data upon which a proposal will be based. In submitting this proposal request, the undersigned warrants that he or she has made a diligent effort to verify the information contained herein; and that, to the best of their knowledge and belief, such information accurately represents the facts; and that no pertinent information has been omitted or altered.

 

  
 
 

LIC.# OD40556

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