Provider Stop Loss Request for Proposal

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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. Provider’s 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

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