Forms

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

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190 West Germantown Pike, Suite 200
East Norriton, PA 19401
Tel: 610.940.9000
Fax: 610.940.9022