CLAIMS

We do provide a short turn-around time for claim reimbursements typically within 3-5 business days provided all required documentation is submitted.

Specific Excess Claims Submissions

Completed MRM Specific Reimbursement Request,
Itemized bills and/or proof of loss*,
Re-pricing sheets, if available,
EOB including check number and paid date,
Individual Payment Report (RIP) or another history report,
Enrollment form and any changes,
Evidence of deductible and out-of-pocket coinsurance,

When applicable:

Large Case Management Reports/Notes

Pre-cert for any in-patient admission

Signed claim form indicating if other insurance is primary

Subrogation information and copy of signed release

COBRA election form and evidence of premium payment

Fulltime Student Status verification

Specific reimbursement requests must be in excess of $100.00. Please combine your requests whenever possible, and submit them as one (unless it is the final request). Unless other arrangements are made, all claims must be fully funded by the employer. Please refer to the funding requirements below.
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Specific Reimbursement Requirements

The following data must be available on any report or a combination of reports in lieu of hard copy claims, itemized bills, repricing data/sheets, and EOBs. Please note; all other reimbursement-filing requirements remain unchanged:

Date of service for all procedures
Place of service
Diagnosis codes for all procedures
Procedure codes whether CPT, HCPC, or Revenue Codes (for in and outpatient procedures)
Modifiers (affects anesthesia, multiple surgeries, and radiology procedures)
Amount of discount or over U&C applied
Ability to identify if the provider is PPO or OON
Co-pays, Deductible and Coinsurance applied (accumulator screen print is not acceptable as it is not always reliable due to incorrectly adjusted claims)
Provider name (preferably the group and the individual name to verify duplicates)
Amount paid
Date paid and check number
Copy of pre-certs for procedures/admissions that require pre-certification

Claim types that require a copy of the HCFA or UB and/or itemization

Inpatient admissions with billed charges in excess of $100,000 and physician bills in excess of $50,000
High dollar multiple surgery bills (on a case by case basis)

MRM reserves the right to request additional information, including medical records, operative reports, screen prints, or itemized bills as needed, for any claim.
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50% or Potential Claim Notification

This form should be completed if any of the following situations occur:

An ongoing claim approaches or has exceeded 50% of the specific deductible.

There is a potential for a large claim and the diagnosis appears on MRM's Trigger Diagnosis Codes.

There is confinement of greater than 30 days.

A confinement is an out-of-network or out-of-the-area.

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Advance Specific Requirements

Subject to all provisions and terms of the treaty, the carrier will advance specific excess loss reimbursement benefits to the treaty holder to the extent that such eligible claims exceed the specific deductible. The plan must have paid the providers to which such eligible claims relate all amounts equal to the specific deductible shown in the treaty.

Advancements for specific excess loss reimbursements are not available for the amount of less than $2,000.

Incurred claims must be reported and paid before the end of the contract period.

Specific Advance will cease if the treaty is canceled or terminated for any reason.

Specific Advance will cease if the treaty holder does not pay the required premium.

Advancement of funds will only be made to the treaty holder.

Advanced funds may only be used to pay providers for eligible claims in accordance with the plan.
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Simultaneous Funding Requirements

Requests must be received within 7 (seven) days of the last check run.

Each request must exceed 10% of the specific deductible.

MRM must receive these requests during the contract period.

Requests in the last 30 days of the contract period require prior notification and approval by MRM.

Simultaneous funding is not available once the contract year has ended.

Simultaneous funds issued to the TPA/Employer must be deposited immediately upon receipt and all associated checks placed in the mail simultaneously.

Stop-loss premium must be current for the month in which the request occurs.
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Aggregate Excess Claim Submissions

1. Detailed claim report prepared/run according to the contract basis with:

Incurred dates of service

Amount charged for individual claim

The amount and paid date for individual claim

Payee/Provider name

Claimant name and YTD totals for each claimant

2. Check Register; if voids & refunds are not included provide a separate report,

3. Outstanding un-recovered overpayments,

4. Prescription drug invoices (when applicable) with administrative fees identified,

5. Monthly census counts (accommodations),

6. Eligibility Listing (final aggregate only) must include:

Coverage and benefit types identified,

Effective and termination dates for all employees and their dependents eligible during the contract period in question,

7. MRM Aggregate Excess Risk Form, (or TPA equivalent)

8. TPA Reimbursement Request,

9. Detail report of specific claims,

10. Total claims paid outside fund or ineligible (i.e. exceptions),

11. Benefit analysis report (amount paid by benefit code or service type),

12. Bank Statements, copies of deposits and/or wire transfers for the entire contract period and the month following the last month (final aggregate only),

13. Completed Funding Questionnaire (final aggregate only).
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MRM must receive accommodation requests by the 15th of the month following the calculation period. Accommodations must be in excess of $1,000.00 unless it is the final reimbursement.

Accommodations will not be issued after the 11th month of a 12/12 contract or the 14th month of a 12/15 contract.

Final aggregate requests should be submitted no sooner than 30 days after the close of the policy period, including any run-out.
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Proof of Payment

Copies of checks or other acceptable claim payment verification is required for a claim to be considered for reimbursement. An example of other acceptable claim payment verification is a computerized explanation of benefits listing check number, check date, check amount, and payee.

In instances where a specific advance reimbursement is requested, actual claim payment verification is required on all amounts up to the specific retention only. On amounts over the specific retention, the date you complete processing the claim is considered the payment date. Other claim payment verification documents should be submitted to us for approval.
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Usual, Customary & Reasonable Charges

Usual, customary, and reasonable (UCR, R&C) calculations are required on surgery, assistant surgery, anesthesia, medical standby, and some consulting services unless otherwise specified in the plan document.

Most contracts exclude expenses resulting from services that are billed in excess of the UCR charge for the locality where administered or an amount which is in excess of the plan benefits.
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Specific Excess Claims Submissions

Specific Reimbursements Requirements

50% or Potential Claim Notifications

Advace Specifc Requirements

Simultaneous Funding Requiremnts

Aggregate Excess Claims Submissions

Proof of Payment

Usual, Customary & Reasonable Charge

Marlton Risk Management LLC
457 Oakshade Rd., Suite 1
Shamong, NJ 08088

www.marltonriskmgmt.com
Office Hours M-F 9AM-5PM

CLAIMS