July 31, 2010  Forms - Plan Sponsor member | provider | advisor | plan sponsor New Group Setup Administrative Forms Special Authorization Forms Claims Forms Specialized Forms/Questionnaires To print and/or view a form, please click on a link below. To save to your hard drive for viewing and/or printing at a later time, right-click on the link, click "Save Target As", and select where you want to save the file on your hard drive. Indicates a secure file, downloadable by authorized users only. Passwords will be changed regularly for security reasons. If you are a plan sponsor and wish to view the file, or believe you may be using an old password, contact ClaimSecure for access.   Note: Some forms require Adobe Acrobat to view. Click below to download Adobe Acrobat Reader:  New Group Setup Form Name Size Format Description Budgeted ASO Banking Form 90KB PDF Forms must be completed for all clients requesting payment to be made on a monthly basis, for predetermined amounts. Reconciliation will occur at a predetermined basis. Claim history tape specifications – Dental and EHC 240KB PDF An interactive document that contains previously paid claim detail and data format elements for electronic file submissions. Eligibility tape specifications 441KB PDf An interactive document that contains member/dependent coverage details and data format elements for electronic file submissions. Master application 1.86MB Microsoft Word An interactive document that captures plan design details on Health, Dental and Life/disability coverage. Stoploss Application   64KB PDF Application to be completed by plan sponsor when applying for stoploss coverage. Travel Health Application   118KB Microsoft Excel Application to be completed by plan sponsor when applying for travel health coverage. back to top  Administrative Forms Form Name Size Format Description Administration manual – Health and dental 84KB PDF User guide for administering health and dental benefit programs. Benefit guide – All   95KB PDF Generic employee booklet of health and dental programs highlights, usage guidelines and contact information. Benefit guide - Drug   123KB PDF Generic employee booklet of drug programs highlights, usage guidelines and contact information. Claim Invoice - Plan   99KB PDF Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures. Claim Invoice - Group Summary   94KB PDF Invoice identifying claim detail by benefit line. Breakdown includes submitted and paid transaction volumes and expenditures. Enrollment Form   160KB PDF Form is to be completed when enrolling new employees or changing existing coverage information. Explanation of Benefits - Sample   341KB PDF Statement describing submitted and paid claim details by line of benefit, explanation of adjustments and/or rejections and address details. Master Contract - Sample   Can't Find File or No Access Microsoft Word Sample contract identifying roles and responsibilities of each party, coverage details, privacy details and rate information. Monthly Employee Roster - Sample   419KB PDF Billing statement listing insured individuals, their respective coverage, volumes and coverage status, premium information and taxes. OAD Eligibility Form   167KB PDF Form is to be completed when enrolling a new over-age-dependent or changing existing coverage information. Premium Billing Statement - Sample   319KB PDF Billing statement listing insured services, coverage volumes, coverage status, rate information and taxes. Spending Account Specifications 221KB PDF Spending Account Deposit Input Specifications for Hssa or Wellness benefits Stoploss SecurePak - Specific   254KB PDF Policy identifying stoploss coverage details and coverage exclusions. Stoploss SecurePak - Specific Plus   254KB PDF Policy identifying stoploss coverage details and coverage exclusions. Stoploss SecurePak - Aggregate   253KB PDF Policy identifying stoploss coverage details and coverage exclusions. TPA Enrollment Form   230KB PDF Form is to used for Third Party Administration (TPA) when enrolling new employees or changing existing coverage information. Travel Health Policy   402KB PDF Policy identifying travel coverage details and coverage exclusions. Web connectivity requirements – EXISTING client 122KB Microsoft Word Document lists minimum hardware and software requirements for user(s) of ClaimSecure web services. Web administration manual – Health and dental 5.64MB PDF User guide for managing web eligibility. Web connectivity requirements – NEW client 275KB Microsoft Word Document lists minimum hardware and software requirements for user(s) of ClaimSecure web services. back to top  Special Authorization Forms Form Name Size Format Description Anti-Obesity   58KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. Drug list   196KB PDF List of drugs that may be classified as “Requires Special Authorization” by the plan sponsor. Erectile Dysfunction   62KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. Standard   79KB PDF Claim form to be completed when individual is applying for a drug that requires clinical review prior to approval. back to top  Claim Forms Form Name Size Format Description Dental   237KB PDF Form is to be completed when submitting a dental claim for reimbursement. Be sure to include an original receipt along with completed claim form. Drug   161KB PDF Form is to be completed when submitting a drug claim for reimbursement. Be sure to include an original receipt along with completed claim form. Health Service Spending Account (HSSA)   132KB PDF Form is to be completed when submitting a HSSA claim for reimbursement. Be sure to include an original receipt along with completed claim form. Hospital   77KB PDF Form is to be completed when submitting a hospital claim for reimbursement. Be sure to include an original receipt along with completed claim form. Extended Health Care   30KB PDF Form is to be completed when submitting a major medical claim for reimbursement. Be sure to include an original receipt along with completed claim form. Vision   34KB PDF Form is to be completed when submitting a vision claim for reimbursement. Be sure to include an original receipt along with completed claim form. back to top  Specialized Forms/Questionnaires Form Name Size Format Description Nursing Care Assessment Form   176KB PDF Questionnaire is to be completed when submitting a Nursing Care estimate. Be sure to complete all required information and submit an estimate, prior to approval Wheelchair Rental Questionnaire   178KB PDF Questionnaire is to be completed when submitting a Wheelchair estimate. Be sure to complete all required information and submit an estimate, prior to approval Hospital Bed Assessment Form   150KB PDF Questionnaire is to be completed when submitting a Hospital Bed estimate. Be sure to complete all required information and submit an estimate, prior to approval Custom Knee Brace Questionnaire   126KB PDF Questionnaire is to be completed when submitting a Custom Knee Brace estimate. Be sure to complete all required information and submit an estimate, prior to approval back to top