Second Dollar Stop Loss (Reimbursement)

The Second Dollar Stop Loss (Reimbursement) reimbursement tool performs second dollar stop loss calculations based on the day reimbursement exceeds a specified dollar amount threshold. This tool functions like the Second Dollar Stop Loss tool, but it calculates based on when the reimbursement liability exceeds a specified threshold rather than when charges exceed the threshold.

The threshold amount can be based on either the number of days or an amount. After calculating the reimbursement as of the threshold day or threshold reimbursement liability, the Second Dollar Stop Loss (Reimbursement) tool resets the days/charges to the threshold value so that subsequent tools can perform calculations based on the days or charges above the threshold.

You can either specify a number of days to use as the threshold or calculate the threshold day based on a reimbursement threshold amount.
- Select Calculate the threshold day to base the threshold on an amount.
- Select Use the threshold day to base the threshold on a specified number of days.
If you calculate the threshold day based on an amount, you can uses the threshold from the previous term, or you can set a specific amount for this tool. You can also choose to use an average daily reimbursement rather than the actual.
If you calculate the threshold day based on an amount, you can specify any service types you want to exclude from the threshold determination.

Field Descriptions

The following table describes the fields on the Second Dollar Stop Loss reimbursement tool.

Field	Description
Threshold Options
Calculate threshold day	Option to calculate the threshold based on reimbursement liability rather than days; the reimbursement options are not available until you select this radio button
Use reimbursement threshold instead of value from previous term	Select to use a reimbursement-based threshold rather than the threshold defined in a previous term
Set reimbursement threshold amount	Uses the value entered as the reimbursement threshold for second dollar stop loss
Use average daily reimbursement instead of actual reimbursement	Select to use the average instead of the actual daily reimbursement to calculate the threshold
Service Types to exclude from threshold determination	This section allows you to specify the service types, if any, that should be excluded when calculating the threshold day To add a new service type, click the Plus (+) button. A new row is added to the table. To select a service type, click in the Service Types to exclude column and select a service type from the list. To remove a service type, click the Minus (-) button for the row you want to remove. You are asked to confirm that you want to remove the row. Click OK.
Use the threshold day	Option to calculate the threshold based on a specified number of days rather than reimbursement liability; the days options are not available until you select this radio button
Set threshold day	Uses the value entered as the number of days to use as the day threshold for second dollar stop loss
Calculation Options
Include the day the threshold is exceeded	Includes all reimbursement liability on the day the threshold is met when using the operand “calculated threshold amount”.
Pay all pass-throughs regardless of the threshold date	Captures and calculates the reimbursement for pass-thru items without consideration to the occurrence date or threshold reimbursement
Exclude pass-through charges from REMAINING DETAIL CHARGES ADJUSTED amount	Excludes pass-through charges from the Remaining Detail Charges Adjusted amount.
Exclude exclusion charges from REMAINING DETAIL CHARGES ADJUSTED amount	Excludes exclusion charges from the Remaining Detail Charges Adjusted amount.
Exclude non-billable charges from REMAINING DETAIL CHARGES ADJUSTED amount	Excludes non-billable charges from the Remaining Detail Charges Adjusted amount.