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Questionnaire: Stop-Loss TPA Questionnaire

Entity, Location, Ownership, Affiliation:

Name: _____________________________________________________
Address: _____________________________________________________
_________________ __________ ______________________
City, State, Zip Code


T.I.N. #__________ Type of Business: Corporation Partnership Sole Proprietor

List of Officers: (Attach additional list if necessary. Submit resumes of Officers, Directors and Owners)
Vice Pres.__________________________

Please list other companies with whom you have financial interest (i.e., insurance companies, PPO's, HMO's, MGU's, Brokerage operations, etc.)




In the last 5 years has your business entity ever been involved in a merger?
N_____ Y_____ If yes, please describe:

In the last 5 years has your business entity ever had a change in ownership?
N_____ Y_____ If yes, please describe:

Has your business entity had a change of name, and /or use a d.b.a. or is it operating under an assumed name? N____ Y____; if yes, previous name was ________________________________

Branch Offices:



Systems-Administration And Claims (Hardware & Software)

Administration Claims

l. Is system on-line or manual?__________________________
ll. Name of Software system______________________________
lll. Who developed? _____________________________________
lV. Year of development__________________________________
V. Is software lease, timeshared, or owned?________________
Vl. If owned, year purchased________________________
Vll. Name of hardware ________________________________
Vlll. Is hardware leased, timeshared or owned? ____________
lX. Have you ever changed/upgraded systems, within 12mo? ___________________________________
if Yes, please describe:

Administrative Services (Financial, Eligibility, & Premium Accounting)

Staff: Total number of employees in department _________
Name/Job Title of key Personnel & Managers, Yrs. Experience, Yrs. w/current Employer
________________________ ___________ ________________

________________________ ___________ ________________

________________________ ___________ ________________

________________________ ___________ ________________

________________________ ___________ ________________
If necessary, list additional names on a separate page & attach. Please attach resumes.

1. May clients have system access in their offices? N_____ Y_____; if yes, which administrative functions can the client perform?__________________________________________________

2. Can you provide census and premium data electronically? N_____ Y_____

3. System(s) Security & Audit Procedures:
l. Describe Security for master file: (ie, who can enter new groups, changes).

ll. Describe security for client funds.___________________

lll. Describe record retention program for enrollment cards, billing files, etc.

lV. Describe back-up system in the event that the computer master file is destroyed.

1. Does your system calculate individual or group premium? N_____ Y_____; Or, are they manually calculated and entered in the master file? N_____ Y____

2. Describe procedures for adding, deleting and changing Plan Participants and their benefits. _____________________________

3. Do you perform bank account reconciliations on Client Accounts? N_____ Y______

4. How often do you generate premium billings?_____________;On what days?___________________

5. When are premium reminder notice sent ________________

6. When are lapse notices sent?____________________________

7. On what dates(s) are premium payments run for insured & reinsures?________________






Staff: Total number of employees in: adjudication support___________ managers___________

Name/Job Title of Key Personnel & Managers, Yrs. Experience, Yrs. w/current Employer ___________________________ ________ _______________
___________________________ ________ ________________
___________________________ ________ ________________
___________________________ ________ ________________
___________________________ ________ ________________
If necessary, list additional names on a separate page & attach. Please attach resumes.

1. How many terminals are in use? _________________

2. Is eligibility determined on-line? N______ Y______

3. How long is claim history maintained on-line? ____________

4. Has the department been audited by a third party for accuracy/security? N_____ Y_____; if yes, how recently, give name of audit firm: __________________________________________

And type of audit: CPA/5500 CPA/Performance Carrier/MGU Independent Claims Audit

5. Can you provide claim data electronically? N_____ Y_____

6. Claims are largely (ie: +75%) a) processed: Manually_____ On-Line_____
b) filed: By family_____ By day batch______

7. What does a claim represent? (check one) line item_______ Check______
E.O.B._________ other______________

Based on the above definition:
a) Average number of claims processed per processor per hour is________________

8. What is your payment accuracy objective?
a) Statistical: Number of claims paid ____________
b) Financial: Dollar amount paid without error _________

9. Describe the payment authority limitation for the claims staff and describe the criteria for internal audits.____________________________________________________

10. What is your payment accuracy performance during the last twelve months?

11. What is your turnaround objective? ____________________________________________

12. What is your turnaround time over the last twelve months?__________________________

13. Surgical R&C is based upon: HIAA___ Internal___ MDR___ Med-Index___ Other___;
if other, please describe:

14. Is your R&C database on-line? N____ Y____

15. How often is R&C data updated?_________________________

16. Are ICD-9 codes captured? N_____ Y_____

17. Are CPT codes captured? N_____ Y_____

18. For what period of time are hard copy claims files retained?________________________




19. Are separate bank accounts maintained for each client? N_____ Y_____
a) What is included in each account?______________________________________
b) Who has disbursement authority?______________________________________
c) Is their is a trust established for Funded Plan? N______ Y______; Describe a "typical" clients funds transactions thru your office_____________________________________________________

20. Do you subcontract any data processing activities? N____ Y______; if yes, please specify __________________________________________________________
Do you utilize off site or home claim processors? N_____ Y______

21. Describe your procedures for professional Medical & Dental Claim review:

22. Describe your procedures for auditing and/or negotiating provider bills:

23. Describe your procedures for using Large Case Management (LCM):

24. Describe the Managed Care Procedures your are using:


1. Please list the stop-loss carriers with which you have business:
Carrier, Name, # of Cases, # of Lives, Annual Premium $$







2. Has any carrier terminated their relationship with you in the last 5 years? N___ Y____; if yes, who and why___________________________________________________________________________________________________________________





Compliance/ Legal/ License

1. Describe any previous or pending material lawsuits in the last 10 years_______________

2. Have any of the principals in your firm or any of your employees (former or current), ever been indicted or convicted of mishandling/misappropriating any insurance company or client funds? N__ Y___; if yes, please give details____________________________________

3. Describe your current procedures for handling client or insured complaints and State Insurance Department complaints._______________________________________________

4. Has the TPA or its principals ever been adjudged bankrupt? N___ Y____; if yes, please explain ______________________________________________________________________________________________________________________

5. Have you been involved in an audit by the Department of Labor? N___ Y___; if yes, please give details. ________________________________________________________________________________________________________________________

6. If your operating jurisdiction(s) requires licensing, are you licensed as a:
Third Party Administrator Managing General Agent Agency Broker Agent In which state(s) for each?
Please provide a copy of current license(s) listed above.

7. How are you kept informed of changing legal requirements within your market area?
How do you inform your clients of these changes? __________________________________________________________

Insurance Bonds

1. Do you carry an Errors and Omissions Policy? N____ Y____

2. Do you carry a Fidelity Bond? N*____ Y____
*If you do not have a Fidelity Bond, please provide a copy of your last fiscal year income statement and balance sheet.

3. Do you carry a Professional Liability Policy? N____ Y____

4. Do you require employee bonding? N____ Y_____; if yes, which employees?_________________________________________

5. Have claims been made against any of these policies in the past two years? N___ Y____; if yes, please provided details.____________________________________________________


1. May we conduct an initial and ongoing financial review of your organization and/or principals using an independent agency, such as Equifax or Dun & Bradstreet? N_____ Y_____; if no why ________
2. Principal Banking relationship (to be used as a reference):
Name of Bank
Contact Title


Please use this checklist and provide the following attachments. If one of these cannot be provided, please explain __________________________________________________________
____________ Resumes of Officers, Directors, Owners, and Key Personnel
_____________ Copy of each: Errors and Omissions Policy, Professional Liability Policy, and/or Bond now in effect
_____________ If applicable, Last 2 Fiscal Year Income Statement and Balance Sheet
_______________ Copy of TPA, MGA, Agency, Broker and Agent License for each applicable state
_______________ Marketing Proposal
_______________ Marketing Brochure
_______________ Sales Literature on PPO and Managed Care
_______________ Service Agreement
_______________ Premium Account Flowchart/Description
_______________ Claim Account Flowchart/Description
_______________ Sample Billing
_______________ Disclosure Form (P.T.E. 84-24)
_______________ Evidence of Good Health Form
_______________ Samples of Administrative Services Reports available to insurers and/or reinsurers
_______________ Samples of Claims Reports available to insurers and/or reinsurers
_______________ Sample Plan Document

I certify that the information on this application is accurate to the best of my knowledge and belief. I understand that a routine inquiry may be made of any or all of the individuals and firms noted herein as references.