Stop Loss Claims

Tokio Marine HCC's team of professional and knowledgeable claims personnel ensures timely and accurate claims auditing while providing responsive service to clients. In addition to handling reimbursement claims, the Preliminary Claim Unit (PCU) and Specialty Claim Unit (SCU) are also under the claims division and provide assistance with determining cost-saving measures.

Specific and Aggregate Claims

Whether your client has a specific or aggregate reimbursement claim, the professionals at our claims department are dedicated to reviewing all requests quickly and accurately.

Tokio Marine HCC - Stop Loss Group provides the Notification & Specific / Aggregate Stop Loss & Life Claims Guide to assist third party administrators with questions regarding early claim notification, specific and aggregate claim filing.

Preliminary Claim Unit (PCU)

The Preliminary Claim Unit (PCU) is responsible for receiving early notification of potential stop loss claims via 50% notices, large case management reports and pre-certification data. With early notification of potentially high dollar expenses, PCU works to identify which expenses could be reduced. Any reduction in costs will help reduce costs for the plan and stop loss carrier.

The PCU staff works with payors to explore repricing options in order to reduce plan costs. PCU assists with out-of-network claims, claims with questionable charges, network claims with minimal discounts and/or excess charges and charges for ongoing treatments, such as dialysis, high cost infusions, chemotherapy and radiation.

PCU staff also contacts payors for information such as current course of treatment and claims paid / pended to date information to establish potential liability for both reserving needs and underwriting.

Specialty Claim Unit (SCU)

The Specialty Claim Unit (SCU) is one of our valued-added stop loss resources for cost containment to the plan via early case intervention. Through partnerships with payors, case managers and employer groups, our team of dedicated professionals can provide access to preferred vendors. Excellent outcomes and effective cost containment are dependent on early notification.

Transplants

Transplantation has more than doubled in the last seven years. In an effort to combat high costs, we have developed strategic alliances and established preferred rates with the leading transplant networks throughout the United States. These networks include LifeTrac Network, Optum Healthcare, 6 Degrees, Multiplan Network, Interlink, Mayo Clinic and Cigna Lifesource. Partnering with these networks provides:

  • Policyholders the ability to offer more choices to their employees
  • Case rate financial arrangements for the entire transplant process, typically including the pre-transplant workup, the transplant event and the followup care for 12 months post-transplant
  • Upon contact, the staff evaluates the submitted information and initiates referrals for charges to the appropriate vendor(s).

Premature Infants

According to the National Institutes of Health (NIH), currently one in eight babies is born premature. Through the combination of our experience and the expertise of our preferred neonatal vendor, the SCU helps assure best outcomes and controls the financial risks to the plans through the following:

  • Referral to neonatal specialists for both care management and physician-to-physician collaboration on the treatment plan
  • Providing continuous care plan oversight
  • Monitoring length of stay
  • Conducting forensic bill reviews and bill negotiation
  • Identifying levels of acuity, experimental therapies, unbundling and errors in billing

Specific Claims

Susan Steelman
Claims Manager
(770) 693 6425
ssteelman@tmhcc.com

Beth Hester
Claims Manager
(770) 693 6501
ehester@tmhcc.com

Aggregate Claims Contact

Julie Christopher
Claims Manager
(770) 693 6452
jchristopher@tmhcc.com

PCU Contact

Patricia Harrington
Clinical Nurse Manager
(770) 693 6578
pharrington@tmhcc.com

SCU Contact

Michael Watson
Clinical Nurse Manager
(770) 693 6408
mwatson@tmhcc.com