The clinical notice form should be used by the medical management staff to notify Summit Re of potential cases where Summit ReSources may be of assistance to you. Use the clinical notification triggers list as a guide. The list is not all inclusive, so feel free to submit a clinical notification on any case for which Summit Re may be of assistance to you.
- High cost pharmacy, such as Flolan, Factor VII, Factor VIII, Cerezyme / ICD-9: 272.7, 286.0, 415.0, 416.0, 416.8
- Major burns with a potential for a prolonged hospitalization / ICD-9: 941.0, 942.0, 943.0, 945.0, 948.2-9
- ESRD/dialysis with monthly dialysis costs greater than $10,000 / ICD-9: V56.0, V56.8, V45.1
- Major injuries or multiple trauma with a potential for a prolonged hospitalization and/or acute rehabilitation admission
- Premature infants with one or more of the following:
- gestational age ≤ 24 weeks / ICD-9: 765.0
- severe congenital heart disease, e.g. hypoplastic left heat, Tetralogy of Fallot, etc. / ICD-9: 746.7, 746.01, 746.89, 745.2
- severe gastrointestinal anomalies, e.g. gastroschisis, omphalocele, necrotizing enterocolitis, short bowel syndrome, etc. / ICD-9: 756.79, 777.5, 777.8, 579.3, 756.79
- severe bronchopulmonary dysplasia requiring long term ventilator treatment / ICD-9: 770.7
- Out of network services with minimal or no negotiated discounts
- Billed charges that greatly exceed reasonable and customary for the services rendered – refer before the claim is paid
- Questionable charges, such as unbundling or experimental treatments
- Cases with the potential to exceed the reinsurance deductible
- Multiple inpatient stays
Submission Process for Clinical Notices
- Use the clinical notification triggers list as a guide for completion of clinical notifications submitted to Summit Re.
- It is recommended that the clinical notices be submitted from the medical management department as they are usually the department first notified of a request for services.
- Complete the Clinical Notification Form (all sections that apply to your case).
- Completed forms may be faxed to 260-469-3014, emailed via encrypted software to firstname.lastname@example.org, or mailed to Summit Reinsurance Services, 7030 Pointe Inverness Way, Suite 350*, Fort Wayne, IN 46804.
- In lieu of the clinical notification form, you may submit a report containing similar information.
*Address updated when this article was converted to this post in 2014.