Notification Form
One of the most important responsibilities of the administrator is the timely notification to IOA Re and Professional Resource Network of any claims with large loss potential . Large loss is defined as: Any claim for which the total paid is expected to exceed 50% of the specific deductible. A form titled Notice of Potential Large Claim/50% Notification (see attached) is required to be completed by you when the loss has either reached or is expected to reach 50% of the deductible.
The Notice of Potential Large Claim/50% Notification Form provides notice of any claim, which may have the potential to exceed the specific deductible for any member.
In addition to expenses exceeding 50% of the deductible, a Notice of Catastrophic Case must be submitted to the Professional Resource Network for the following conditions:
- Intensive Neonatal Care
- High Risk Maternity Case (Expected Multiple birth, High risk Premature Birth)
- Transplantation, including solid organ, bone marrow and/or peripheral stem cell
- Inpatient Extensive Acute or Rehabilitation Admission greater than 5-day duration
- Traumatic Brain Injury Involving Coma
- Severe 2nd or 3rd Degree Burns Requiring Hospitalization
- Major Trauma/ Injury
- Guillain-Barré Syndrome
- Amyotrophic Lateral Sclerosis
- Spinal Cord Injury with Paralysis
- Malignant Neoplasm
- Leukemia/Lymphoma
- Major Cardiac Surgery, Severe Cardiovascular compromise
- ESRD (Renal Disease & dialysis)
- Ventilator Dependency
- Major Small & Large Bowel Procedures, Obstruction, Pseudocyst, Crohn’s
- Hemophilia and Von Willenbrands Disease Requiring Factor
- Any other claim where lengthy hospitalization or extensive care (acute and/or post-acute) is expected
- Member with a Multiple In-Patient Admissions during the Policy Period
Right click on the link below and choose “Save As…” to download the form:
> Early Notice Form <
If you have any questions about this form or reporting a claim with large loss potential please contact us at 800.462.2300.
To report a claim notice, please contact:
Iantha Dukes, Senior Claims Auditor/PRN Liason
Office: 800-462-2300 Ext. 309
Fax: 610-940-9022
To reach Professional Resource Network:
Anthony Dorosz, Accountant/Senior Project Coordinator
Office: 800-462-2300 Ext. 271
Fax: 610-940-9022
190 West Germantown Pike, Suite 200
East Norriton, PA 19401
Tel: 610.940.9000
Fax: 610.940.9022
