Managed Care Insurance Consultants - Reinsurance Provider Stop Loss Insurance Health Insurance Group Insurance Construction Insurance

Managed Care Insurance Consultants - Reinsurance Provider Stop Loss Insurance Health Insurance Group Insurance Construction Insurance

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Our customers enjoy distinctive and personal attention to assist them in all personal and commercial lines of insurance needs.  Our level of administration efficiency in underwriting and actuarial support permits us to pass on the savings to our clients in the form of lower than average premiums.

 

 

Provider Stop Loss Request for Proposal          

The Coverage is designed to follow the obligation for benefits to the members of the Managed Care Organization(s) as provided for in the Capitated Provider Agreements. 

After completing the form below press or

1.      Provider's Legal Name:
2.      Providerís Date of Incorporation:
3.      Address:
4.      Contact:Title:
         Phone:             Fax:
5.      Provider Type (i.e., Hospital, Hospital System, Physician Group, PHO, etc.):
       
6.      Date of Incorporation: 
7.      Proposed Effective Date:
8.      Date Quote Needed:
9.      Expiration Date of Present Coverage:
10. Broker Company & Name, if applicable
      Address:
      Phone:         Fax:

CAPITATION CONTRACTS
Please identify the name of each capitating MCO (Managed Care Organization) and attach the risk/financial responsibility matrix for each - we must have this to quote.  On each matrix, please identify (1) those services for which you are capitated, and (2) those services which you have either sub-capitated* or entered into a risk sharing agreement with another provider to deliver.

*Services for which you receive capitation from an MCO yet pay a capitation to another provider to perform services

Membership should reflect the number of capitated members for the most recent month

Name of MCO   Risk/Financial
Matrix
Attached (Yes/No)  
Capitation
Agreement Attached?
(Yes/No)  
Monthly Members Commercial   Monthly Members Medicare   Monthly
Members
Medicaid  
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No
Yes/No Yes/No

Please Note
:  Final premium rates and coverage are subject to receipt of
capitation and subscriber agreement(s) and a list of all affiliates to be insured
under this policy.

COVERAGE REQUESTED
A. Retention (Deductible) Amount:
 1) Hospital:  $30,000     $50,000     $75,000     $100,000     $125,000
    Other
 2) Physician:  $7,500     $10,000     $15,000     $ 20,000     $ 25,000
    Other
B. Coinsurance (Percent payable on amounts in excess of the Retention Amount):
      70%          80%          90%    Other %
C. Maximum Covered Hospital Expense
 1. Policyholder Hospital:
    Eligible charges to be calculated based on:
    a) % of Reasonable & Customary charges and/or
    b) Per diem:
       $ACU     $NICU   $ICU   
       $Burn    $Extended Care/Rehab
     Facility      
       $CCU    $Home Health
       $Chemical Dependency Facility
  2. Referral/In-Area Emergency Hospital Services
       Eligible charges to be calculated based on:
       a)      Amount Paid
       b)      % of Reasonable & Customary charges
       c)      HMO Reciprocity Rate (please attach)
       d)      Per diem:
  $ACU    $NICU   $ICU
  $Burn    $Extended Care/Rehab Facility
  $CCU    $Home 
  $Chemical Dependency Facility
3. Out-of-Area Emergency Hospital Services
   Eligible charges to be calculated based on the amount paid not to exceed
   reasonable and customary allowances in the area where services are rendered.
List Hospitals Below:
COVERAGE REQUESTED continued   
D.  Maximum Covered Physician Expenses
  1.  Policyholder Medical Group
        Eligible charges to be calculated based on:
        a.      % of RBRVS
        b.     McGraw-Hill Schedule (include Conversion Factors)
        c.   CRVS (include Conversion Factors)
        d.   Other fee schedule (specify, include schedule in CPT-4 coding)
2. Referral/In-Area Emergency Physician Services
     Eligible charges to be calculated based on:
        a.  Amount Paid
        b.  HMO Reciprocity Rate (please attach)
        c.  % of RBRVS
        d.  Other Fee schedule (specify)
3. Out-of-Area Emergency Physician Services:
    Eligible charges to be calculated based on the amount paid not to exceed
    reasonable and customary allowances in the area where services are rendered.
E.  Maximum Benefit Payable per covered person per contract per policy year:
     $
MANAGEMENT OF CARE
Please indicate your case management methods for:
                                               In-House                                  External
  RN Other (Specify Other)

Peer
Review

MCO Contracted (Specify Vendor)
Over Utilization
Length of Stay
Quality of Care
Appropriateness
of Care
Approval of Referrals
Medical Necessity
Catastrophic Care
Terminal Illness Care
Outcome Studies
Concurrent Review
Discharge Planning 

Use this space for any additional comments on your ability to manage risk:

REFERRAL SERVICES
The following information is asked in addition to the financial responsibility/risk matrix information already requested. For those services listed below and for which you are at risk, please provide the name of referral facilities utilized to perform services not delivered by your organization:
Organ Transplant    Performed by Provider 

Name(s) of Referral Facility(ies)

Liver  Yes/ No
 Kidney Yes/ No
Heart  Yes/ No
Lung  Yes/ No
Bone Marrow Transplant Yes/ No
Other Yes/ No
NICU    
Level I  Yes/ No 
Level II Yes/ No 
Level III Yes/ No
Trauma Center  Yes/ No
Burn Yes/ No
Cardiac Care Yes/ No
Oncology Services Yes/ No
Physical Rehabilitation Yes/ No
Chemical Dependency Yes/ No
Mental Health Yes/ No 

Note
:  Please Fax a copy of any agreements with Referral Facility(ies) including reimbursement terms and conditions to 305-485-0867.

INITIALS OF PERSON REQUESTING QUOTE

Initials    Name    
Title     Company
Date    Email    

 Press after correctly filling out the above fields.
 Press
to clear the form and start over.

 

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