TPA Professional: Administrative Guide

Manual Overview

Purpose of Guide

This Administrative Guide is not intended to replace your policy. It has been designed to assist the Claims Administrator and Broker with 50% notifications, claim filings, aggregate reports and general information regarding the Stop Loss Policy. An understanding of our process, procedures and services that we provide will ensure effective communication and a smooth claim filing process. This Administrative Guide will also provide sample forms and request letters for your convenience.

This Administrative Guide is provided to our Administrators as a reference guide only. Information contained in this Administrative Guide is subject to change at any time at the discretion of Kanawha Insurance Company (KIC), a Humana Company. No information contained in this Administrative Guide will supersede the terms and conditions of the Stop Loss Policy or take the place of any direction provided by authorized employees of KIC.

If at anytime you have any questions, please feel free to contact one of our stop loss teams listed on the contacts page at the end of this Administrative Guide.

Important Notice: [For Administrator Use only. Not for dissemination to the public.]

Maximized Outcomes Medical Management - MOMM

Our Medical Management programs help our Claims Administrators keep patient care and costs in the best possible balance: always seeking to maximize clinical and financial outcomes. By contacting our Medical Management team when an Administrator identifies an out of network claim, an abnormally high claim for a diagnosis/treatment, our services can be utilized to reduce costs. Our team can complement your existing managed care with many free or below market price consultative services. They can deliver highly specialized guidance in complex, high cost cases and help save the Policyholder money through exclusive preferred pricing.

MOMM Services Available to the Administrator

Transplant Deductible Opportunities
Members who are transplant candidates
		Access to Transplant Centers of Excellence nationwide
		Transplant Network access & referral assistance
		Lower Stop Loss Deductible (step down deductible see levels below)
		• $10,000 step down for deductibles $35,000 - $75,000
		• $20,000 step down for deductibles $75,001 - $100,000
		• $30,000 step down for deductibles $100,001 - $150,000
		• $40,000 step down for deductibles $150,001 or higher
Claim Negotiation Opportunities
Inpatient & Outpatient non-contracted out of network
		Customized simple referral to vendor from Administrator identifying rates & rewards
		Available to all Administrators for all claims
		Reimbursement of vendor fees up to 30% of saving
Predictive Modeling Opportunities
State of the art claim analysis
		User friendly access to individual and group clinical and financial data that improves the ability to impact outcome
		Reporting that can streamline underwriting and renewal processes
		Better ability to report and analyze data and results of interventions
		Significantly reduced rates with our preferred vendors
Renal Disease Management Opportunities
Members with stage 4-5 ESRD
		Ability to access network discounts via re-pricing
		Direct negotiations with dialysis facilities
Other Cost Containment Opportunities
For members with catastrophic or complex health conditions
		Customized simple referral to appropriate vendor
		Vendor fees considered for reimbursement as a specific claim in some instances

Reimbursement Guidelines for Vendor Fees

Access to effective cost containment vendors has become a key component in the management of potential high dollar claim costs. Integration of these services into your claim management process can assist you in controlling your overall claim costs.

In recognition of the value of these services, Humana Specialty Benefits will consider vendor fees for case management and out of network/large claim negotiations as an eligible charge under the excess risk claim reimbursement.

Under Humana Specialty Benefits' Maximized Outcome Medical Management (MOMM) program, we offer our partner Claim Administrators access to a broad array of cost containment vendor contracts.

The following guidelines apply:

	As our partner, you have automatic access to our vendor contracts, providing an opportunity to lower your claim costs, regardless of whether the claims are below or above the Specific Deductible.
	When vendor access fees are incurred and the claims are in excess of the Specific Deductible, these fees are eligible for reimbursement. When using Humana Specialty Benefits vendor contracts, the full fee is eligible for reimbursement.
	When using a non-contracted vendor, fees may be eligible for reimbursement, with the following limitations
	•	Fee equivalent up to 30% of savings if fees are calculated on a % of savings basis
	•	Case management services up to $125 per hour, with prior approval.
	•	All other cost containment vendor fees will be considered on a case by case basis and require prior approval to be eligible for reimbursement
	Vendor fees will be billed directly to the Administrator and, when eligible, can be submitted to KIC for reimbursement consideration via an excess risk claim submission.

Specific Excess Risk

Large Claim Notification (LCN)

Large Claim Notification should be submitted as soon as identified for all claimants who have catastrophic diagnoses (see trigger diagnosis list) and/or have reached, or will reach, 50% of their Specific Deductible.

To submit a Large Claim Notification, complete a Specific Excess Risk Claim Notification Form (see forms section) and attach all supporting documentation. As an alternative method, a case management report can also be sent as a notice. The notification can be sent to KICExcessRiskClaims@humana.com.

Administrators are encouraged to send notification for any claimant that has the potential to be catastrophic in order to utilize our MOMM Program. Recommended reasons for notification are:

	Review of Vendor Fees - all vendor fees must be approved prior to reimbursement
	Treatment requiring medical necessity review
	Experimental/Investigational Treatment
	Non-PPO Claims for potential negotiations

Notification Requirements

The following information is required when filing a Large Claim Notification:

	Completed Specific Excess Risk Claim Notification Form #1479
	Age of claimant
	•	For Premature infants - Gestational age, date of birth and congenital anomalies
	Diagnosis (list all)
	•	Are there any secondary diagnoses or medical issues that impact this patient's care/recovery?
	Date of onset
	Current Treatment Plan
	Future Treatment Plan (surgery, transplant, chemo)
	Current Clinical Status
	Are all services being provided by a network facility/provider?

Trigger Diagnosis List

To view the Trigger Diagnosis List, click here.

Specific Claim Notification

A specific claim should be filed when total benefits paid on behalf of a Covered Person exceed the Specific Deductible amount. To request reimbursement, complete a Specific Excess Risk Claim Notification Form #1479 (see forms section) and attach all supporting documentation. The reimbursement request should be sent to KICExcessRiskClaims@humana.com or a hard copy mailed to our office (see contact section).

Initial Claim

Outlined below is the supporting documentation required when filing for reimbursement:

	Completed Specific Excess Risk Claim Notification Form #1479 or a cover letter outlining the expected amount of reimbursement. At times the amount of reimbursement that is calculated from a claim detail report differs from the amount a Policyholder / Claims Administrator is expecting and an outline of their understanding helps to ensure a smooth reimbursement process.
	Provider bills and corresponding EOBs
	•	This documentation requirement refers to the HCFA physicians bills. If the EOB (Explanation of Benefits) format is sufficient (meaning that it captures all of the claim data elements that we need), a HCFA physicians bill would not be required. Therefore, an EOB can satisfy this requirement, but we reserve the right to request a HCFA physician bill on an as needed basis.
	A computer print-out of a claim detail report that includes the following:
	•	Employer/Group Name
	•	Employee Name
	•	Claimant Name
	•	Dates of service
	•	Provider Name
	•	Types of Service
	•	Diagnosis (ICD-9 codes)
	•	Procedure Codes (CPT codes)
	•	Total billed amounts
	•	Benefits paid
	•	Ineligible or denied amounts
	•	Deductibles and Co-pays
	•	Voids and refunds, where applicable
	•	Check Numbers
	•	Dates paid
	•	Total payment line
	Copy of original enrollment card/form including hire date and coverage effective date
	•	A copy of the original enrollment form is the preferred documentation; however, we will accept a screen print if the enrollment form is not available and/or if the group has online/electronic enrollment. Accepting written verification (directly from the group), in lieu of this documentation, is reviewed on a claim-by-claim basis since eligibility is a core requirement.
	Applicable eligibility information:
	•	Located in the forms section of our guide is our work status request letter. This fill in the blank form outlines exactly what information is needed when we are reviewing LOAs / continuation of coverage issues on a claim. Specifically, we need to be able to determine how (via sick leave, FMLA, STD or a combination) coverage was maintained for all dates that the employee is not actively at work. Additionally, we have to verify that the types of leave applied are compliant with the leave provisions allowed under the SPD (Summary Plan Document) / LOA policy. (It is not uncommon to find employee-specific exceptions to the SPD in this area, which in many cases may not be covered under the Excess Risk policy.) Also, please note that since most SPDs require that premium be paid throughout the leave period, we usually ask for documentation from the payroll / benefits system that verifies that premiums were paid for the period of leave.
		• Status of employee (i.e. active, retired, FLMA, medical leave of absence, etc.)
		• Termination date
		• Last date worked
		• Return to work date
		• FLMA effective date and end date
		• In many cases, the group will have paperwork on file indicating that an employee was placed on FMLA. FMLA is typically unpaid leave, but it may run concurrently with STD / LTD. Therefore, proof of premium is still needed. (Please also provide a copy of the STD / LTD policy or handbook if it is not address in the SPD.)
		• Copy of COBRA election form
		• Medicare effective date and qualifying event
		• The Medicare primary rules can be very complex (especially when disability and ESRD is involved), and we must thoroughly investigate these claims.
		• Certificate of Creditable Coverage or verification of a pre-existing conditions
		• Other Insurance Information
		• This is a core documentation requirement. Ideally, we would like to have documentation completed and / or signed by the employee. Especially with dependent coverage, there is always opportunity for other coverage. As a rule of thumb, we would expect the administrator to verify / update OI the earlier of every 12 months or at point of claim. If there is a substantial time gap between the time when OI was verified and the date of claim, we will ask for updated verification since changes that impact coverage could have occurred. If OI information is captured via an electronic enrollment, a screen print can sometimes satisfy this requirement. Our level of flexibility with regard to OI verification is limited because of the potential financial impact that primary / secondary status can have on the claim.
		• Student Status documentation
	Other information needed, if applicable:
	•	UB-92 for inpatient and outpatient bills over $100,000
	•	Hospital pre-certifications with actual contact date
	•	Date and details of accident and police report
	•	• All accident claims are referred to our subrogation vendor for an initial assessment and disposition. Therefore, this information is required on any claim that has an accident code. If the claim is identified for a subrogation investigation / potential recovery, we will coordinate updates with the Claims Administrator and broker, as appropriate.
	•	Peer review, in-house review, external review of large claims
	•	Case management reports
	•	For all Policyholder’s that have a domestic reduction, a list of all affiliates must be provided

Note: In certain cases, it may be necessary to request additional information not listed above before a claim reimbursement determination can be made.

Please Note - Reimbursement will not be made without the following:

	A fully executed and approved plan document on file
	Paid to date premiums

Turn Around

Time Our commitment to claim turnaround is to have a claim 'reviewed' within 10 business days. The 'review' would result in a reimbursement being made or first contact to the Administrator has been made. If all of the necessary information is not received, the administrator will receive a letter outlining what is required. As a standard, our turnaround time will decrease with a more complete filing.

Appeals Process

If an Administrator wishes to appeal a claim, written notification and additional documentation should be submitted to the claims department within 60 days of receiving the reimbursement decision. If possible, a written decision on the appeal will be rendered within 30 days. If a decision is not possible, the appeal decision will be extended an additional 30 days and written notification will be sent to the Administrator.

Pre-Determinations

As a Stop Loss carrier, we do not make claim pre-determinations. Benefits should be processed by the Administrator, in accordance with the Policyholder's Summary Plan Document (SPD). If the claim reaches/exceeds the Specific Deductible level, we will evaluate the claim in accordance with the SPD language and the Stop Loss Policy to determine if the claim is eligible for reimbursement under the contract terms of the Stop Loss Policy.

Aggregating Specific

For Policyholders that have an Aggregating Specific provision, that Policyholder is responsible for all claims over the stated Specific Deductible up to the Aggregating Specific Deductible. In return, the Policyholder receives a certain amount of premium relief for sharing in the risk. Claims that are submitted with an Aggregating Specific Deductible are processed in the order in which they are received and that have all valid claim documentation. Explanations of Reimbursements (EOR) are supplied as the Aggregating Specific Deductible is applied.

Subsequent Claim

After an initial reimbursement has been made, all additional filings are subsequent claims. Outlined below is the information needed when filing a subsequent excess risk claim:

	Completed Specific Excess Risk Claim Notification Form #1479
	Provider bills and corresponding EOBs
	A computer printout of a claim detail report that includes the following:
	•	Employer/Group Name
	•	Employee Name
	•	Claimant Name
	•	Dates of service
	•	Provider Name
	•	Types of Service
	•	Diagnosis (ICD-9 codes)
	•	Procedure Codes (CPT codes)
	•	Total billed amounts
	•	Benefits paid
	•	Ineligible or denied amounts
	•	Deductibles and CO-pays
	•	Voids and refunds, where applicable
	•	Check Numbers
	•	Dates paid
	•	Total payment line
	Other information needed, if applicable:
	•	UB-92 for inpatient and outpatient bills over $100,000
	•	Hospital pre-certifications
	•	Peer review, in-house review, external review of large claims
	•	Case management reports

Subrogation

Subrogation allows the Policyholder to recover medical expenses paid for a covered employees' injuries when those injuries resulted from the actions of a third party. Our policy contains a subrogation provision that grants us the right to recover up to the amount we’ve reimbursed if a Policyholder receives a recovery of those claims. This policy applies even after termination of the policy.

Currently we work with a third party subrogation vendor. This subrogation vendor assists us with coordinating with the Administrator to determine if a third party recoverable is due. If so, the subrogation vendor will coordinate directly with us to ensure that any recoverable due to us is remitted in accordance with the right of recovery provision outlined in the policy.

Advanced Funding

Specific Advanced Funding is a benefit that waives the requirement that claims in excess of the Specific Deductible be paid prior to a reimbursement request being submitted.

Outlined below are the provisions that must be satisfied for advanced funding:

	Claims up to the Specific Deductible for a covered person must be paid
	Eligible expenses are those that exceed the sum of the Specific Deductible
	The minimum amount eligible for advancement is $1,000.00
	The Administrator must clearly identify the request for advanced funding at the time of claim submission
	Payments must be made to the appropriate providers within 5 days of receipt of advancement
	A complete claim submission with the request for advanced funding must be received within 14 days prior to the end of the contract plan year. Any claim reimbursement request submitted after that date must be Paid and fully funded by the Policyholder.
	The Policyholder must have an in force Excess Risk policy. Request made after termination of a policy will be considered not paid and will not be eligible for reimbursement.
	The Policyholder's premiums must be current.

Aggregate Excess Risk

Monthly Reporting Requirements

Administrators are required to submit Monthly Aggregate Reports within 15 days after the close of each calendar month, for any Policyholder who has purchased Aggregate coverage. The Monthly Aggregate Report should include the census by coverage type and claim summaries for each month of the Policy Period, as well as deductions for ineligible claims such as Specific claims, voids and/or refunds and extra-contractual claim payments. Electronic copies of these reports can be submitted to KICExcessRiskClaims@humana.com and hard copies can be mailed to the address located in the contacts section.

Minimum Aggregate Attachment Point

The Minimum Aggregate Attachment Point is the total number of actual covered employees for a given policy month multiplied by the corresponding Aggregate Monthly Factor per covered person. The Minimum Aggregate Attachment Percentage is shown on the schedule of benefits.

(Monthly Aggregate Attachment Point x [12]) x (Minimum Aggregate Attachment Percentage)

Claim Filing Requirements

An aggregate claim should be filed when actual paid claims exceed the Aggregate Attachment Point. To request reimbursement, please submit the following information:

Year End Aggregate Claim

	Completed Aggregate Excess Risk Claim Notification Form #1487
	Detailed Paid Claims Report based on the Benefit Period of the Aggregate coverage, which provides claimant's name, incurred date, charged amount, paid amount and paid date with a grand total for each claimant.
	Eligibility listing of all employees covered at any time during the Policy Period, including COBRA participants, which identifies effective date, termination date and coverage type.
	Benefit Type/Service Code report based on the Benefit Period of the Aggregate coverage
	Proof of funding to include bank statements and/or deposit slips for the Policy Period, including 2 months after.
	Void and Refund report based on the Benefit Period of the Aggregate coverage, including three months after.
	Aggregate report
	Specific report showing claimants that have exceeded the Specific Deductible
	Detailed Paid Claims report based on the Benefit Period of the Aggregate coverage, which lists payments made outside the Aggregate contract (i.e. Dental, Weekly Income, Vision, RX Administrative Fees)
	Outstanding subrogation log
	Copies of itemized RX invoices, if RX is covered under the Aggregate contract

Desk Audit

When appropriate, we may choose to perform a Desk Audit (see definitions) rather than an On-Site audit. If so, we will request additional information from the Administrator.

Items may include:

	Check register
	Administrator billing reports
	Sample individual claims

On Site Audit

Usually, our aggregate claims auditor will schedule an On-Site claims audit (see definitions) at the Administrator's office and will provide a list of information needed to be available for audit review.

Items may include:

	Enrollment and eligibility documentation
	Check register
	Administrator billing reports
	Sample of individual claims

Premium Remittance

	Premium payments are due on the first day each month
	Payment must be submitted along with the Premium Remittance Form #1476
	Customized worksheets are permitted if they include the following information:
	•	Group name
	•	Policy number
	•	Month for which payment is being made
	•	Coverage
	•	Number of lives/volume
	•	Rates
	•	Adjustments
	•	Gross Amount Due
	•	Compensation Deduction
	•	Check Amount
	All premium payments should be made payable to
		Kanawha Insurance Company A Humana Company C/O Wachovia Bank PO Box 75117 Charlotte, NC 28275-0117 Overnight Address: Wachovia Bank, N.A. Humana Specialty Benefits P.O. Box 75117 1525 West W.T Harris Blvd – 2C2 Charlotte, NC 28262 If sending premium via wire transfer: Kanawha Insurance Company A Humana Company C/O Wachovia Bank PO Box 75117 Charlotte NC 28275-0228 DDA Acct # 2003206517716 Routing #053207766
	Premium remittance forms can be emailed to PremiumRemit@KMGAmerica.com
	A Grace Period is allowed for payment of your premium. If premium is not received before the end of the Grace Period, the Policy could be lapsed due to non-payment of premium. Please refer to your Policy for specific contract language.

Definitions

Case Management is a collaborative process that assesses plans, implements, coordinates, monitors and evaluates the options and services required to meet the policyholder's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.

Claim Negotiation is the direct negotiation of provider claims (hospitals, physicians, medical specialty facilities), by a claim negotiation company.

Desk Audit is an aggregate audit that is completed at our office.

Disease Management educates patients about their disease and how to better manage it. This includes encouraging proper medication use, better understanding of symptoms, behavior change, monitoring of symptoms and treatment plans based on standardized guidelines and the coordination of care among all providers.

Experimental/Investigational means that according to reliable evidence:

	A device, drug or medicine cannot be lawfully marketed because it has not been approved by the US Food and Drug Administration
	A treatment, procedure, device, drug or medicine is the subject of ongoing phase I, II, or III clinical trials
	The opinion among experts regarding a treatment, procedure, device, drug or medicine is that it requires further study to determine its maximum tolerated doses, its toxicity, its safety, or its efficacy
	Treatments, services or supplies that are educational or provided for research
	Treatments, procedures, devices, drugs or medicines relating to transplants of non-human organs, tissues or cells

[Please refer to the Policy Definitions]

Issued means the date that a check or draft addressed to the payee is placed in the U.S. Mail or other delivery service. Issued also means the date that funds are electronically tendered to the payee. [Please refer to the Policy Definitions]

MOMM, (Maximized Outcomes Medical Management), our medical management program

On-Site Audit is an aggregate audit that is completed at the Administrators office.

Paid means that checks, drafts or electronic payments were Issued on behalf of the Plan, so long as there were sufficient funds for payment at the time Issued and when first presented for payment. [Please refer to the Policy Definitions]

Paid Claims are checks, drafts or electronic payments issued on a claim account of the Policyholder.

Policyholder the entity named in the application and on the face page of the policy.

Predictive Modeling analyzes claims and other data to identify high risk claimants who are then given risk scores based on diagnoses, claims history and any potential co-morbidities. This service allows for timelier medical management interventions.

Forms/Letters

Humana Specialty Benefits Administrative Guide - Excess Risk
Specific Excess Risk Claim Notification (1479)
Specific Claim Additional Information Letter
Aggregate Excess Risk Claim Notification (1487)
Aggregate Claim Additional Information Letter
Premium Remittance Form (1476) - Sample

Contact Information

MOMM Program
210 South White St., (or PO Box 7050)
Lancaster, SC 29720
Phone 800-635-4252 ext 5796
MOMM@KMGAmerica.com

Excess Risk Claims Department
210 South White St., (or PO Box 7050)
Lancaster, SC 29720
Phone 800-635-4252 ext 5484
Fax 803-313-5258
KICExcessRiskClaims@humana.com

Premium Accounting Department
210 South White St
Lancaster, SC 29720
800-635-4252
PremiumRemit@KMGAmerica.com