|
Document To Accompany The Application |
|
The following documents and
information are required in order to process your request. Please check
all items attached. |
|
Copy of capitation
agreement(s) with HMO(s) or responsibility matrix. |
|
Physicians: Fee Schedule to be applied, (CRVS including conversion factors,
RBRVS, McGraw-Hill,Percentage of Charges, etc.) |
|
Hospitals: Copy of Hospital Inventory reflecting the services available at
your facility |
| Copy
of benefit plan(s) in current use for members under capitation (not required
for quote). |
| Sample
copies of the current provider contracts (primary physicians, specialty
physicians, etc.). |
| Any
demographic information that you can provide the underwriters may result in
a lower rate. |
| Please
include all enrollees from the past three years who: |
1. have reached 75% or more of the deductible requested;
2. are in the hospital on the date indicated; and are expected to exceed
75% of the deductible requested;
3. are under treatment for a serious condition which can be expected to
exceed 75% of the deductible requested in total
expenses before the medical problem is resolved; or
4. have been identified as candidates for a major operation or extensive
care. |
|
Show for each of the
above: |
|
1. name or I.D.
number
2. Diagnosis/prognosis
3. Expenses incurred to date
4. Expected final expense total
5. Currently hospitalized
6. If hospital Coverage is to be quoted: If possible, provide a breakdown
of Med/Surg days, ICU and SNF and Home
Health and Rehab. Facility Days. |
