Common Contracts
2 similar null contracts
Managed Care Specific Excess Loss Reinsurance AgreementDecember 2nd, 2022
Claim ReimbursementRequest: Selec Covered Entity: Agreement #: Population Type: SelectCovered Plans, HMO or MCO Name: t Claim ~Basis: Select Policy Period: to Name of Covered Person: Date of Birth: (Last Name, First Name) Covered Person Unique ID #:Current Status: Select Claim is Due to: Select Automobile Accident: SelectDiagnosis: Will Medical Expenses be Paid by:Auto Insurance: SelectMedicare: SelectPrognosis: Effective Date: Termination Date: Wor k Related Claim: Select Third Party Subrogation Applies: Select Workers Compensation: Reason for Medicare Eligibility: Select Select Other (COB etc.): Sele ct Medicare Effective: (please include expected treatment) Amount Reported This Claim: Expenses Incurred Thru Date: Less Specific Deductible: Expenses Paid Thru Date: Coinsurance Percentage: Estimated Additional Costs: REIMBURSEMENT REQUEST: Signature: Title: Date: Direct inquiries to: PartnerRe America Insurance Company, Attn: C
Managed Care Specific Excess Loss Reinsurance AgreementDecember 2nd, 2022
Claim ReimbursementRequest: Covered Entity: Agreement #: Population Type: SelectName of Covered Person: Claim ~Basis: Select Effective Date: to Date of Birth: (Last Name, First Name) Covered Person Unique ID #: Effective Date: Current Status: Select Termination Date: Claim is Due to: Select Work Related Claim: Select Automobile Accident: SeDlieacgtnosis: Third Party Subrogation Applies: Select Diagnosis: Will Medical Expenses be Paid by: Other (COB etc.): Se Auto Insurance: Select Workers Compensation: Select Medicare: Select Reason for Medicare Eligibility: Select Medicare Effective: Prognosis: (please include expected treatment) Amount Reported This Claim: Expenses Incurred Thru Date: Less Specific Deductible: Expenses Paid Thru Date: Coinsurance Percentage: Estimated Additional Costs: REIMBURSEMENT REQUEST: Signature: Title: Date: Direct inquiries to: PartnerRe America Insurance Company, Attn: Claims Department, 6900 Wedgwood Road N
