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Available Forms for Download

Large Claim Identification Medical Case Management

File type: PDF

Claim Submission Checklist

File type: PDF

Medical Claims Data Submission Guide

File type: PDF

Rx Claims Data Submission Guide

File type: PDF

Network Questionnaire

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Notification Form

File type: PDF

Claim Form

File type: PDF

Premium Transmittal Form

File type: XLS

Form W-9

File type: PDF

Form W-9

File type: PDF

Unlimited Coverage Waiver

File type: PDF

Unlimited Coverage Waiver

File type: PDF

Standard Disclosure

File type: PDF

Standard Disclosure

File type: PDF

Specific Stop Loss Claim

File type: PDF

Specific Stop Loss Claim

File type: PDF

Specific Stop Loss Claim

File type: PDF

Monthly Aggregate Report

File type: XLSX

Monthly Aggregate Report

File type: XLSX

Monthly Aggregate Report

File type: XLSX

Direct Deposit Authorization Form

File type: PDF

Billing Template

File type: PDF

Billing Template

File type: PDF

Billing Template

File type: PDF

Application for Stop Loss Insurance

File type: PDF

Aggregate Stop Loss Claim

File type: PDF

Aggregate Stop Loss Claim

File type: PDF

Direct Deposit Authorization Form

File type: PDF

Aggregate Stop Loss Claim

File type: PDF

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Stop Loss coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, in all states except New York under policy form series HMP-SL (11/16), HMP-SL (08/19) or HMP-SL (06/20) or similar. In New York, Stop Loss coverage is underwritten by HM Life Insurance Company of New York, New York, NY, under policy form series HMP-SL (11/16), HMP-SL (08/19) or HMP-SL (06/20) or similar. In all states except New York, Managed Care Reinsurance coverage is underwritten or reinsured by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA, under policy form series HM PEL 1105, HC PEL 1105, HMP PEL (08/19), HMP PEL (09/20), HML 1105 ELR, HMC 1105 ELR, HM 1005-ELR or similar. In New York, Managed Care Reinsurance coverage is underwritten under policy form series HMNY PEL 1105 or similar or reinsured by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. Reinsurance agreements only reflect a form number when required by applicable state law.

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Stop Loss coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, in all states except New York under policy form series HMP-SL (11/16), HMP-SL (08/19) or HMP-SL (06/20) or similar. In New York, Stop Loss coverage is underwritten by HM Life Insurance Company of New York, New York, NY, under policy form series HMP-SL (11/16), HMP-SL (08/19) or HMP-SL (06/20) or similar. In all states except New York, Managed Care Reinsurance coverage is underwritten or reinsured by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA, under policy form series HM PEL 1105, HC PEL 1105, HMP PEL (08/19), HMP PEL (09/20), HML 1105 ELR, HMC 1105 ELR, HM 1005-ELR or similar. In New York, Managed Care Reinsurance coverage is underwritten under policy form series HMNY PEL 1105 or similar or reinsured by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. Reinsurance agreements only reflect a form number when required by applicable state law.

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