Stop Loss Program Sample Clauses
A Stop Loss Program clause establishes a financial arrangement where an insurer or reinsurer limits its exposure to large or catastrophic losses by capping the total amount payable for claims within a specified period. In practice, this means that once the aggregate claims paid by the insurer reach a predetermined threshold, the stop loss coverage activates and covers additional losses above that threshold, up to a maximum limit. This mechanism is commonly used in health insurance or reinsurance agreements to protect against unexpectedly high claim volumes. The core function of the clause is to provide financial stability and predictability by preventing excessive losses from overwhelming the insurer or reinsurer.
Stop Loss Program. (1) For the Stop Loss Program Charges set forth in Part D below, Blue Shield shall reimburse Group for eighty percent (80%) of that portion of the Allowable Costs (as described herein) of Capitated Professional Services provided during any one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level and which are Group’s financial responsibility under the Agreement.
(2) In addition to the defined terms of the Agreement, the following terms have the following meanings for this Stop Loss Program:
(i) The Attachment Level is ten thousand dollars ($10,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Commercial Member (including POS Members) in any one (1) Agreement Year. The Attachment Level is fifteen thousand dollars ($15,000) of Allowable Costs incurred by Group for the provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus Member in any one (1) Agreement Year.
(ii) Allowable Costs (both for determining the Attachment Level and Stop Loss Program reimbursement after the Attachment Level is reached) are the lesser of the amount actually paid (other than capitation payments) by Group for such Capitated Professional Services, or ninety percent (90%) of the Blue Shield’s PPO Physician Allowances in effect at the time. Allowable Costs are reduced by: (a) the Member’s applicable Copayments; and (b) any amount for which Group is entitled to reimbursement or payment from any other source.
(3) Group shall submit to Blue Shield any claims for Stop Loss Program reimbursement within ninety (90) days of the end of the Agreement Year in which the services, for which Stop Loss Program reimbursement is claimed, were provided. Blue Shield may deny any claims not submitted within said time period. Claims shall be in such form, containing such information, and provided to Blue Shield as set forth in the Provider Manual.
(4) Stop Loss Program reimbursement is provided only for Capitated Professional Services which are provided to an eligible Member in conformity with the terms and conditions of the Agreement, including, without limitation, any provisions requiring Authorizations and case management program notification and cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is not paid for any monetary compensation payable to a Member for any reason, including Group’s negligence in providing or arranging or failing to provide services.
(5) Group shal...
Stop Loss Program. PROVIDER's Stop Loss threshold shall be ----------------- $50,000.00 per Medicare Risk Member during the contract year of the Agreement (each April 1st through each March 31st). If the PROVIDER projects the costs of providing services to a Member will reach the $50,000.00 threshold, PROVIDER shall refer the Member to HMO's Care Management Department, at point of determination. PROVIDER shall submit claims under the applicable stop loss program no later than sixty (60) calendar days following those days of service which occur beyond the threshold. Failure to submit claims in a timely manner may result in forfeiture of PROVIDER's right to reimbursement. For purposes of determining if the stop loss threshold has been reached, the compensation schedule set forth in Fee-For-Service Addendum shall be the source rates for calculation. HMO shall compensate PROVIDER for claims in excess of the stop loss threshold at eighty percent (80%) of the Fee-for-Service rates in the applicable Addendum, except for drugs which will be reimbursed at AWP minus ten percent (10%), less applicable Copayments, coinsurance, deductibles and payments from third parties or coordination of benefits.
Stop Loss Program
Stop Loss Program