Standard Operating Procedure
OPS-SOP-006 — Stop-Loss Reporting & Reimbursement
ℹ️ Stop-Loss Overview
Individual Stop-Loss (ISL): Reimburses Unity's plan for claims paid on behalf of a single member that exceed the ISL threshold within a contract year. Unity pays first; reinsurer (HLRA via Brown & Brown) reimburses above the threshold.
Aggregate Stop-Loss (ASL): Provides program-level catastrophic protection. If total plan claims across all participating employer groups exceed the aggregate corridor, the reinsurer (HLRA) reimburses the captive above the corridor threshold.
1. Purpose
This SOP defines the procedure for monitoring individual and aggregate stop-loss thresholds, preparing reimbursement claim packages, submitting claims to the reinsurer (HLRA via Brown & Brown) through the broker, tracking payments, and reporting aggregate exposure to Finance and Leadership under each participating employer plan under the Unity Care Member Plan Master Trust.
2. Scope
Applies to all reinsurance monitoring and reimbursement activities for each participating employer plan under the Unity Care Member Plan Master Trust. Covers weekly member-level tracking, ISL breach response, reimbursement submission, aggregate corridor monitoring, and evidence retention.
3. Roles & Responsibilities
| Role | Responsibility |
|---|
| Operations | Weekly cumulative claims tracking per member. Alert Finance at ISL thresholds. Coordinate claim package preparation and submission. |
| Finance | Validate reimbursement amounts received. Record receivables in GL. Monitor aggregate corridor exposure. Alert Leadership at ASL thresholds. |
| Reinsurance Broker (Brown & Brown) | File ISL claims with reinsurer (HLRA via Brown & Brown). Track claim status. Facilitate payment. |
| Compliance / Legal | Review claim packages for completeness and compliance. Retain evidence per ERISA. Advise on disputed reimbursements. |
| Reinsurer (HLRA) | Review and pay valid ISL claims above threshold. Administer ASL corridor per contract. |
| Leadership | Informed at ASL 75% threshold. Approves any plan-level financial decisions triggered by aggregate exposure. |
4. Procedure
Subprocess reference: SUB-009 (Stop-Loss Notification & Reimbursement flow)
1. Weekly Claims Data Receipt: Operations receives the weekly claims register from Allied (see OPS-SOP-001). Paid claims data is used for stop-loss tracking.
2. Update Cumulative ISL Tracker: Operations updates the ISL Tracker [TBD] with each member's cumulative paid claims for the contract year to date. Tracker is updated within [TBD] business days of each register receipt.
3. ISL 80% Alert: When a member's cumulative paid claims reach 80% of the ISL threshold:
- Operations alerts Finance of the approaching threshold
- Finance begins reviewing claim documentation in anticipation of a potential ISL breach
- Operations begins preparing claim package components (see Step 5)
4. ISL Breach: When a member's cumulative paid claims breach the ISL threshold:
- Operations confirms breach amount (claims paid above threshold)
- Finance is notified immediately
- Claim package preparation is initiated (Step 5)
5. Prepare ISL Reimbursement Claim Package: Operations compiles the reimbursement claim package:
- Stop-loss carrier claim form (per carrier template)
- Paid claims detail (above ISL threshold) — PHI handling per carrier instructions
- Proof of payment (bank confirmations, GL records)
- Eligibility verification for the member (active, enrolled, coverage window)
- Compliance review of package completeness
6. Submit to Reinsurance Broker (Brown & Brown): Operations submits the claim package to the broker for filing with the reinsurer (HLRA via Brown & Brown). Submission is logged with date/time in the ISL Tracker [TBD].
7. Track Claim Through Payment: Operations monitors claim status with the broker on a [TBD] basis. If no status update received within [TBD] days, Operations follows up with broker. All status updates logged in ISL Tracker.
8 — Payment Received: When reimbursement payment is received:
- Finance validates payment amount against expected reimbursement (claims above ISL threshold)
- Finance records receivable in GL and reconciles
- Operations updates ISL Tracker: status = Paid
- All documentation retained per Evidence Retention table
8 — Payment Not Received / Disputed: If payment is not received within [TBD] days or carrier disputes the claim:
- Operations escalates to broker and notifies Finance and Legal
- Legal advises on remedies per stop-loss contract
- Dispute documented; all evidence retained
9. Monthly ASL Corridor Review: Finance compares total paid plan claims (all members, all services) against the ASL corridor monthly. ASL tracker [TBD] is updated each month.
10. ASL 75% Alert: When total plan claims reach 75% of the ASL:
- Finance alerts Leadership immediately
- Operations and Finance review trajectory and projected year-end exposure
- Reinsurance Broker (Brown & Brown) is notified for carrier awareness per contract requirements
11. Evidence Retention: All stop-loss records retained for 6 years per ERISA. Retention locations recorded in the Evidence Retention Index [TBD].
5. Controls
| Control | Description | Owner | Frequency |
|---|
| ISL Tracker Update | Cumulative per-member claims updated each week from register | Operations | Weekly |
| ISL 80% Alert | Finance alerted when member reaches 80% of ISL threshold | Operations | Per event |
| Claim Package Completeness | Compliance reviews package before broker submission | Compliance | Per claim |
| Submission Log | All ISL claim submissions logged with date/time in ISL Tracker | Operations | Per submission |
| Payment Validation | Finance validates reimbursement amount vs. expected before GL posting | Finance | Per payment |
| ASL Corridor Review | Monthly comparison of total plan claims to ASL corridor | Finance | Monthly |
| ASL 75% Alert | Leadership alerted when aggregate claims reach 75% of ASL | Finance | Per event |
| Evidence Retention | All stop-loss records retained 6 years per ERISA | Operations, Compliance | Per event |
6. Evidence Retention
| Document | Location | Retention Period |
|---|
| ISL Tracker (cumulative, all members) | Finance / Ops shared [TBD] | 6 years (ERISA) |
| ISL reimbursement claim package | PHI-aware secure location [TBD] | 6 years (ERISA) |
| Reinsurance Broker (Brown & Brown) submission confirmation | Ops records [TBD] | 6 years (ERISA) |
| Carrier payment confirmation | Finance records [TBD] | 6 years (ERISA) |
| GL receivable record | Finance records [TBD] | 6 years (ERISA) |
| ASL corridor tracking (monthly) | Finance records [TBD] | 6 years (ERISA) |
| ASL alert communications | Finance / Ops records [TBD] | 6 years (ERISA) |
| Compliance review record | Compliance records [TBD] | 6 years (ERISA) |
7. Escalation
| Trigger | Action | Escalation Owner |
|---|
| Member at 80% of ISL | Alert Finance; prepare claim package | Operations |
| Member breaches ISL | Immediate Finance notification; initiate claim package | Operations |
| No broker status update within [TBD] days | Operations follows up with broker; escalates to Finance if unresolved | Operations |
| Carrier disputes ISL claim | Notify Legal; review contract terms; document all communications | Operations / Legal |
| ASL at 75% | Immediate Finance and Leadership alert; broker notification | Finance |
| ASL projected to breach | Legal and Finance review plan-level financial exposure and options | Finance / Legal |
⚠️ Open Items — Tracking Tools To Be Built
- ISL Tracker: PRIMARY PRIORITY — per-member cumulative claims tracking against individual stop-loss threshold. Must be updated weekly from Allied register. Suggested: Excel workbook or database table with member ID (no names), cumulative claims YTD, ISL threshold, % of threshold, status. Referenced by OPS-SOP-006.
- ASL Corridor Tracker: Monthly total plan claims vs. ASL corridor with trend line. Suggested: Excel with monthly totals and running total vs. ASL. Referenced by OPS-SOP-006.
- Stop-Loss Claim Package Template: Standardized package template matching reinsurer (HLRA via Brown & Brown) requirements [TBD — carrier provides form]
- ISL/ASL Thresholds: Confirm exact ISL and ASL amounts from stop-loss policy [TBD — Finance/Reinsurance Broker (Brown & Brown) to confirm]
- Reinsurance Broker (Brown & Brown) Contact Protocol: Documented contact workflow for broker submission and follow-up (role-based) [TBD]
- PHI Handling Protocol for Claim Packages: How PHI is handled when submitting paid claims detail to reinsurer (HLRA via Brown & Brown) (carrier requirement) [TBD — Legal/Compliance to define]
- Evidence Retention Index: Cross-reference of all stop-loss records to retention locations [TBD format]
OPS-SOP-006 | Unity Care Solutions, LLC — Internal / Confidential
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