Claim - HealthPlan Services
OHIO HEALTH REINSURANCE PROGRAM (OHRP)
CLAIM REIMBURSEMENT REQUEST FORM
When claim payments have exceeded any applicable deductibles, this form along with all required documentation, should be completed and submitted to:
Self-Funded Plans, Inc.
Attention: Lori Ziegler
1432 Hamilton Avenue
Cleveland, OH 44114
Telephone: (216) 377-7152
Fax: (216) 566-1505
Email: loriz@
Please complete the following and submit with the information listed below:
Carrier Name:
Reinsured Name:
Reinsured/Employee Social Security Number:
Reinsured Date of Birth:
Total Amount Paid by Carrier:
We require claims payment detail which must include at least the following information:
a. Reinsured name
b. Provider in or out of network (for PPO plan only)
c. Diagnosis code
d. Service code
e. Dates of service
f. Units (days, visits, etc.)
g. Place of service
h. Charge amount
i. Allowed amount
j. Paid amount (carrier liability)
k. Paid date
PLEASE NOTE: IN ORDER TO PROCESS THE CLAIM REIMBURSEMENT REQUEST, WE MUST RECEIVE BOTH THE COMPLETED FORM AS WELL AS THE CLAIM PAYMENT DETAIL LISTING/REPORT.
I certify that, to the best of my knowledge, the above information is correct and the claim has been paid in accordance with the Plan Document.
Submitted by:
Telephone:
Fax:
e-mail:
CARRIER CLAIMS CERTIFICATION
Ohio Health Reinsurance Program – Small Employer
As a member carrier in the Ohio Health Reinsurance Program (OHRP) Small Employer Pool, I hereby certify that this claim is being submitted only to the OHRP Administrator, Self-Funded Plans, Inc. This claim has not been submitted to Summit Administrative Services, Inc. for payment.
I certify that I am an Officer of the undersigned Insurer/Carrier.
(NOTE: THIS CERTIFICATION MUST BE SIGNED BY AN OFFICER OF THE CARRIER.)
__ ________________________________
Signature of Officer
_ _________________________________
Printed Name of Officer
__________________________________
Insurance Co./Carrier Name
__________________________________
Officer’s Title/Office
Date: _____________________________
CARRIER CLAIMS CERTIFICATION
Ohio Health Reinsurance Program – Open Enrollment
As a member carrier in the Ohio Health Reinsurance Program (OHRP) Open Enrollment Pool, I hereby certify that this claim is being submitted only to the OHRP Administrator, Self-Funded Plans, Inc. This claim has not been submitted to Summit Administrative Services, Inc. for payment.
I certify that I am an Officer of the undersigned Insurer/Carrier.
(NOTE: THIS CERTIFICATION MUST BE SIGNED BY AN OFFICER OF THE CARRIER.)
__ ________________________________
Signature of Officer
_ _________________________________
Printed Name of Officer
__________________________________
Insurance Co./Carrier Name
__________________________________
Officer’s Title/Office
Date: _____________________________
................
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