Claims
The Stop Loss Claims Department of NUS is staffed with the experience and knowledge required to provide the highest quality service. With an average of over 15 years experience in the payment of medical claims, our turnaround time averages 10 business days or less.
Stop Loss Claim Guidelines:
NUS requires written notification of a claimant with a diagnosis that has the potential of exceeding the specific deductible and those that have reached 50% of the specific deductible as soon as possible . From this notice, NUS computes an estimate of the total charges and sets a reserve amount in case there is a specific claim violation.
Should a claimant exceed their specific deductible, the following documentation is required for review in order to issue a reimbursement:
· Completed Specific Excess Loss Claim form
· Copy of Enrollment Card
· Copy of all itemized bills
· Copy of COBRA election form along with proof of cobra premium payments
· Copies of all correspondence regarding coordination efforts
· Copies of all Checks, EOB’s or similar proof of payment for each claim
· Large Case Management Reports
· Pre-Certification forms
· If claim will be subrogated, we will need a copy of the signed subrogation agreement from the claimant. If there is a claim filed involving an accident whether subrogated or not, accident details are required. Also if applicable, a police report.
· Any documentation regarding unusual circumstances should also be included with the claims submission.
Once NUS has received all the required documentation, we will proceed to process the claim in accordance with the Stop Loss Policy and Group Plan Document.
Monthly and Aggregate Claim Guidelines:
NUS requires a Monthly Aggregate report be filed monthly for each group to include the following:
· Monthly paid claims
· Monthly Single/Family Enrollment
· Monthly amounts excluded from aggregate
· Monthly claims paid total of those claimants “lasered” on the contract
Note: This report must be in the NUS office within 15 days of the close of the prior month.
Monthly Accommodation and Year-End Aggregate:
The following is a list of all the information needed:
· Proof of Loss – Aggregate Reimbursement Claim Form.
· Claims Paid Listing indicating the following:
Employee Name
Name of Claimant
Service Dates
Type of Service (medical, dental, vision, disability, etc.)
Date of Payment
Amount of Payment
Check and/or Claim Number
Diagnosis Codes
Procedure Codes
· Information and documentation as relates to the receipt, review and payment of prescription drug claims, if applicable.
· Monthly Check Registers
· Documentation regarding Voids and Refunds processed after the policy period pertaining to payments made during the policy period.
· A Claim Benefit Analysis report and/or similar documentation identifying any out-of-contract payments, medical records fees, and administrative fees.
· A listing of all identified, outstanding overpayments relative to payments made during the policy period.
· Recoveries i.e., Coordination of Benefits, Other Party Liability or Subrogation claims and the status thereof, Specific Reimbursements, Duplicate Payment, etc.
· Eligibility report listing Employees and Dependents, Date of Birth, Effective and Termination dates (to include COBRA participants).
· Financial records documenting the funding of claims during the plan year and reconciled bank statements (to include one month after the policy period).
NOTE: Payments made outside of the Stop Loss contract (i.e., prescription drug card, dental, weekly income, vision, etc.) should not be included with the information listed above.