Getting the Big Picture

• Tell me briefly about your current health plan, including enrollment size and whether it is self-funded or fully insured.
• How many employees or covered lives are on the plan today? Options: Under 200, 200-999, 1,000-4,999, 5,000-24,999, 25,000+
• Which funding structure do you use for stop-loss today, for example specific only, specific plus aggregate, level-funded, or another model? Options: Specific only, Specific + aggregate, Level-funded, Captive or rent-a-captive, Other
• Describe a typical year-to-year claims swing for you, either as a percentage or a concrete example of what changed budget to budget.
• Who on your team will be responsible for collecting claims detail and sharing it with the seller during underwriting? Options: CFO, Benefits Director, HR/People Ops, Third-party administrator, Benefits consultant/broker, Other
• If your enrollment dropped below 200 covered lives, would you still pursue a formal stop-loss placement this renewal? Options: Yes, proceed as planned, No, we would delay or change approach, Unsure, need to review budget

Where the Numbers Hide Risk

• If a single claim could force an unaffordable renewal, which claim profile would that be?
• Over the past three plan years, how many individual claims exceeded your current specific deductible? Options: None, 1-2, 3-5, 6-10, More than 10
• How often do you see clusters of large claims concentrated in a short period, for example multiple claims over the deductible in the same quarter? Options: Almost every year, Occasionally, Rarely, Never
• Tell me about known high-cost members you expect to see on submissions and whether they are currently carved out, tracked for lasers, or treated as part of the risk pool. Options: Carved out, Tracked and likely lasered, Included in pool, Unknown / need to check
• What is the largest single claim paid by your plan in the last 24 months? Options: Under $100k, $100k to $250k, $250k to $500k, $500k to $1M, Over $1M
• Which historical claim pattern or recent spike would make you reject a quoted policy outright?

What Keeps You Up at Night

• What renewal surprise in the last two years hit your budget hardest, and why?
• Which element, premium, lasers, terminal liability, or deductible shifting, usually causes the most tension during renewal talks for your team? Options: Premium increases, Laser assignments, Terminal liability gaps, Deductible or corridor changes, Other
• How prepared is your finance team to absorb a one-time cash call for claims that exceed expected run rate? Options: Fully prepared, Can absorb with one-time measures, Would require board approval, Not prepared
• Who inside your organization typically raises concerns about laser language or contract exceptions and when do they enter the conversation? Options: CFO, Benefits Director, Risk Manager, Broker/consultant, Legal, Other
• During the last renewal, what was the primary reason you considered switching carriers or changing coverage? Options: Price, Laser language, Terminal liability gaps, Claims handling speed, Underwriting transparency, Other
• What single budget or board-level constraint would stop you from accepting a renewal even if pricing looked competitive?

Alternatives You Are Weighing

• Who else are you actively talking to about stop-loss and what about them feels like a viable alternative?
• Which of the following alternatives have you evaluated or are you still considering? Options: Incumbent carrier, Another carrier, Captive or rent-a-captive, Increase employer deductible and self-insure, Stop-loss aggregator or program, Internal cost-containment only, Other
• What would have to be true about your incumbent for you to stay with them another year instead of moving? Options: Match best price, Improve laser language, Provide terminal liability coverage, Commit to multi-year rate cap, Other
• Has anyone internally proposed solving high-cost claims without an outside carrier, for example with a captive, a special fund, or direct stop-gap payments? Options: Yes, captive proposal exists, Yes, one-off internal fund discussed, No, not proposed, Not sure
• Which decision criteria do you weigh most heavily when comparing carriers, placing them in order of importance: price, contract terms, claims turnaround, underwriting flexibility, or financial strength?
• If your incumbent matched the most favorable term any competitor offers today, what else would you need to change to stay?

Who Really Decides and How Fast

• When a renewal number lands, who will say yes or no within 48 hours and on what authority?
• Which stakeholders must sign off on stop-loss terms before a contract is executed? Options: CFO, Benefits Director, Risk Manager, HR Head, Board or trustees, Procurement, Broker/consultant, Other
• What approval thresholds or financial limits require escalation to executive leadership or the board? Options: Any single-claim exposure over $250k, Any premium increase over 10%, Any new contract clause that increases employer liability, Other
• How long is your standard procurement or board review window for insurance renewals? Options: Under 2 weeks, 2-4 weeks, 1-2 months, Longer than 2 months
• If a seller can deliver a quote within 48 hours and meet your required exhibits, what internal process would still block a rapid signature?
• Who holds the final sign-off power and under what conditions would they refuse a recommended vendor?

What the Contract Needs to Actually Protect You

• Which contract term have you seen carriers use to shift cost back to your plan at renewal? Options: Laser language, Ambiguous terminal liability, Retroactive rate adjustments, Restrictive advance funding, Other
• Which attachment point structure do you prefer for specific stop-loss? Options: Standard per-person deductible, Layered tiers by population, Aggregate corridor only, Custom blended deductible, Other
• How tolerant is your leadership of lasers applied to known high-cost members and what minimum justification would you require to accept a laser?
• List the run-out or terminal liability options you require if a policy ends mid-year, for example 12-month run-out or claims-incurred coverage. Options: 12-month run-out, Claims-incurred coverage, Immediate cut-off with limited run-out, Custom run-out tied to claim types, Other
• Which funding mechanics do you prefer for large in-flight claims, for example advance funding, escrow, or letter of credit? Options: Advance funding by carrier, Escrow arrangement, Employer pays then submits monthly, Letter of credit, Other
• What measurable acceptance criteria will you use to decide whether a TPA integration and claims workflow meet operational needs? Options: Data granularity (line-level claims), Turnaround time for reimbursements, Daily eligibility sync, Automated claim adjudication flags, Other
• If the seller only offers a partial terminal liability solution, what is the minimum contractual fix you need to proceed?

Operational Readiness and Constraints

• What integration failure during onboarding would force you to pause implementation?
• Which third-party systems must connect before go-live? Options: TPA claims system, Eligibility/roster feed, Payroll/HRIS, Billing/finance system, Data warehouse, Other
• Who owns the API or data feed on your side and can they commit to a delivery timeline? Options: Internal engineering team, TPA technical contact, Third-party integrator, No owner identified yet
• How clean and accessible is your claims data, for example are line-level claims and diagnosis codes available for the last 36 months? Options: Fully available and clean, Mostly available with gaps, Partial data only, Not available
• What internal headcount or technical resources can you dedicate to onboarding and ongoing integrations? Options: Dedicated project manager and engineers, Part-time IT support, TPA handles most work, No internal resources available
• Are there regulatory, procurement, or committee approvals required before starting a new stop-loss relationship? Options: Board approval required, Finance or risk committee approval, Standard procurement review, No external approvals required, Other
• If data cannot be delivered at the granularity the seller requires, can you provide an alternative that preserves underwriting accuracy, or would that stop the deal? Options: We can provide an alternative, That would stop the deal, Unsure, need to evaluate

Deciding and Moving Fast

• If a pilot or proof of concept could validate pricing and claims handling, what outcome would make you sign within 30 days?
• What are your non-negotiable acceptance criteria for a new stop-loss partner? Options: Specific deductible limits, Terminal liability coverage, Underwriting turnaround under 48 hours, Claims reimbursement within 30 days, Rate cap at renewal, Other
• What timeline do you need for underwriting, pilot, and final sign-off to align with your upcoming renewal? Options: Under 2 weeks, 2-4 weeks, 1-2 months, Longer than 2 months
• Who on the buyer side will track implementation milestones and sign acceptance of integration deliverables? Options: Benefits Director, CFO, IT/project manager, TPA contact, Broker/consultant, Other
• Which metrics will you monitor in the first 90 days post-go-live to judge success, for example payment lag, claim accuracy, or reconciliation variance? Options: Claims payment lag, Reimbursement accuracy, Month-to-month spend variance, Dispute rate and resolution time, Other
• Assuming pricing and the integration plan meet your acceptance criteria, what internal barrier could still prevent a timely signature?

• Underwriting and Claims Experience Workshop

• Confirm the current state and its cost
• You confirm that the demonstrated underwriting treatment of your claim scenarios maps to your expectations and reduces renewal uncertainty.
• Provide modeled renewal scenarios showing premium impact for three alternate laser and terminal liability options based on the submitted claim runs, delivered within five business days.
• You confirm that the shown claims reimbursement flow and advance funding option address your cash flow and timing concerns for high-cost claims.
• Run your claim scenario through underwriting assumptions
• Map and deliver the proposed claims reimbursement SLA and advance funding schedule for in-flight high-cost claims.
• Agreement on which contract options and evidence remain required to finalize terms prior to renewal.
• Demonstrate the claims reimbursement and advance funding flow
• Provide 12 months of de-identified, high-cost claim detail and any known potential lasers to validate the models before the follow-up underwriting decision meeting.
• Compare renewal outcomes across contract options
• Schedule the follow-up underwriting decision meeting within ten business days to review modeled outcomes and agree contract language.
• Validate alignment and next steps

• Underwriting and Claims Experience Workshop
• Solution Experience Deck
• Solution Brief - Underwriting and Claims Experience

• meeting
• slides
• document

• Deliver specific stop‑loss quote (≤48 hours)
• Issue aggregate stop‑loss policy
• Configure specific deductible levels on policy
• Provide monthly aggregate attachment reporting
• Perform annual aggregate settlement and reconciliation
• Process and reimburse stop‑loss claims
• Advance funding for in‑process high‑dollar claims
• Activate terminal liability / run‑out coverage
• Document and manage laser provisions on claims
• Integrate claims data exchange with employer TPA
• Provide renewal analytics 90 days prior to expiration
• Offer multi‑year rate guarantees and rate caps

Deliver specific stop‑loss quote (≤48 hours)

• Do you require the standard ≤48 hour underwriting turnaround or a different SLA for initial quotes? Options: Standard ≤48 hours meets needs, Need faster than 48 hours, Need longer review window
• How many distinct employee populations (e.g., locations or unions) should be quoted separately in the submission? Options: 1, 2-3, 4-10, More than 10
• Which attachments should be included with your submission packet (select all that apply)? Options: 12-24 months claim runout CSV, Renewal billing history, Large claim narratives, Provider EOBs / remittance advices, Other supporting docs
• What specific claim artifacts will you provide to support laser evaluation (for example: claimant ID, diagnosis codes, paid amounts, and dates of service)?
• Who in your organization is the primary decision contact for quote clarifications (title and email)?

Issue aggregate stop‑loss policy

• Which aggregate attachment method do you prefer for the policy year (select one)? Options: Fixed corridor dollar amount, Percent of expected claims (specify % in next question), Variable monthly corridor
• What level or percent of expected annual claims should define the aggregate attachment (enter numeric percentage or dollar amount)?
• Which billing frequency do you require for aggregate premium and corridor reconciliation? Options: Monthly, Quarterly, Semi-annual, Annual
• Specify any endorsement or policy form identifiers your legal team requires to be present on the issued policy (policy form ID, amendment titles).
• Are there any explicit exclusions or benefit categories that must be listed on the aggregate policy form (for example stop-loss carve outs for specific programs)? Options: None, Specify exclusions in free text

Configure specific deductible levels on policy

• Which specific deductible options do you want quoted and configured for the policy (select all that apply)? Options: $25,000, $50,000, $100,000, Custom deductible (specify)
• How many employees or covered lives fall into each deductible tier you want configured (provide counts per tier)?
• What is your preferred handling for claim run-in or stop-loss credits when moving members between deductible tiers within the policy period? Options: Pro-rate by service dates, Apply full attachment to new tier, Require manual review
• Which specific member identifiers will you provide for deductible assignment and laser handling (for example: member ID, DOB, plan enrollment file)?
• Will you require different deductible configurations by sub-plan (medical vs carve-outs) or by location? Options: Yes - different by sub-plan/location (will provide mapping), No - single deductible across all sub-plans

Provide monthly aggregate attachment reporting

• Which reporting cadence do you require for aggregate corridor tracking (select one)? Options: Monthly standard report (CSV), Monthly with dashboard access, Bi-weekly
• What columns and data fields must be present in the monthly aggregate report CSV (for example: month-to-date paid claims, member-level accumulators, aggregate corridor remaining)?
• Which delivery method do you prefer for the monthly report file? Options: Secure SFTP drop, Encrypted email, TPA EDI endpoint, Platform dashboard export
• Identify any validation thresholds for the monthly aggregate report that will require exception review (for example: variance > 5% vs. expected)
• Which acceptance criteria will confirm the monthly aggregate attachment report is complete and accepted by your finance team (examples: file delivered by day 10, reconciliation match within $X or Y%)? Options: File delivered by agreed calendar date, Reconciliation within specified tolerance, Signed acceptance email from your finance contact

Perform annual aggregate settlement and reconciliation

• When does your plan year end and do you require a final aggregate reconciliation on a calendar or plan-year basis? Options: Calendar year-end, Plan year-end (specify date), Other
• What reconciliation tolerance will you accept for annual settlement (enter dollar or percentage tolerance)?
• Which supporting artifacts do you expect with the settlement statement (select all that apply)? Options: Member-level accumulators CSV, Claim adjudication ledger, Payment remittance advices, Audit trail of adjustments
• Who is responsible for preparing the draft settlement worksheet and who will sign off from your side (provide role/title)?
• Are post-settlement audits or corrections within scope for this engagement or considered out of scope? Options: Post-settlement adjustments are in scope up to 90 days, Post-settlement adjustments are out of scope

Process and reimburse stop‑loss claims

• Which claim submission formats will your TPA send for reimbursement (select all that apply)? Options: 837 electronic claim files, Claim detail CSV, Paper EOB scanned PDFs, API claim push
• How quickly do you require claim reimbursements to be issued after receipt of a complete claim package (select preferred SLA)? Options: Within 7 business days, Within 14 business days, Custom SLA (specify)
• What documentation will you include with each claim submission to support medical necessity and paid amounts (for example: EOBs, provider statements, clinical notes)?
• Which remittance artifact do you require with each reimbursement (for example: remittance advice PDF, ERA 835, deposit reference)? Options: Remittance advice PDF, ERA 835 electronic remittance, Payment confirmation only
• Which acceptance evidence will validate a claim has been reimbursed correctly (for example: matching paid amount on ERA, signed remittance, reconciliation report)? Options: ERA/835 confirms amount, Reconciliation match to claim ledger, Signed remittance confirmation

Advance funding for in‑process high‑dollar claims

• What maximum advance amount per claim would you require as an advance funding cap (enter dollar amount)?
• Which criteria must a claim meet to qualify for advance funding (select all that apply)? Options: Provider has outstanding billed charges, Claimant inpatient and active, Pending final adjudication but documentation complete, Clinical review approval required
• How do you prefer advances to be documented and recovered (options: offset in final reimbursement, invoiced separately, collateral)? Options: Offset against final reimbursement, Separate invoice with repayment terms, Require collateral
• Who will approve advance funding requests on your side and what supporting documents will you require (role/title and list of docs)?
• Will you require a separate funding agreement or schedule to govern advance payments outside the main policy form? Options: Yes - separate agreement required, No - include advance terms in policy

Activate terminal liability / run‑out coverage

• Which run-out period do you require for terminal liability coverage measured in months after policy termination? Options: 6 months, 12 months, 24 months, Custom (specify)
• Which incurred-versus-paid basis should the run-out coverage use for determining eligible claims? Options: Incurred during policy period, Paid during policy period, Other - specify
• How should late-filed claims that have dates of service in the policy period be treated under terminal liability (provide your desired rule)?
• Which evidence do you require to accept terminal liability coverage for a claim (examples: claim adjudication date, provider invoice, EOB)?
• What acceptance criteria will confirm run-out activation and payout (for example: claim submitted within X months of termination and validated against plan enrollment file)? Options: Claim submitted within run-out window, Matched to policy enrollment and DOS within period, Required supporting docs provided

Document and manage laser provisions on claims

• Which data fields will you provide to support laser determination (for example: member ID, diagnosis codes, lifetime paid totals)?
• Which laser types do you expect to appear on the policy (select all that apply)? Options: Individual-specific deductible addition, Exclusion of services for named member, Shared laser across family members, Temporary laser pending review
• How should lasers be represented in member reports and invoices (for example: separate line item, annotation on member accumulators)? Options: Separate line item, Annotation only, Both line item and annotation
• Who in your organization will review and approve proposed lasers and what turnaround do you require for laser disputes?
• Which governance or acceptance condition should define when a laser is removed or reduced (for example: time-bound review, clinical outcome evidence, cap on duration)?

Integrate claims data exchange with employer TPA

• Which integration endpoints does your TPA support for claims exchange (select all that apply)? Options: SFTP file drop, REST API (JSON), HL7 / X12 837/835, Manual CSV uploads
• What is the expected file layout and field mapping for the monthly claim detail feed (provide sample schema or indicate you will share one)?
• Which authentication method will the integration endpoint require (for example: key-based, SFTP credentials, OAuth2)? Options: SFTP credentials, API key, OAuth2, Mutual TLS
• Who is the technical point of contact at your TPA for integration testing and what is their availability window for test cycles?
• How will you measure integration success during UAT (for example: 100% field delivery, zero parse errors, daily file delivery by 8 AM)?

Provide renewal analytics 90 days prior to expiration

• Which renewal analytics deliverables do you expect 90 days before expiration (select all that apply)? Options: Trend analysis of large claims, Projected renewal premium models, Aggregate corridor burn rate, Member-level loss drivers
• What forecast horizon should the renewal analytics cover (for example: 12 months, 24 months)? Options: 12 months, 24 months, Custom
• Which acceptance threshold will you use to approve the renewal analytics (for example: model variance under X% vs. actuals)?
• Who will be the decision approver on your side for accepting renewal recommendations (title/role)?
• Do you require scenario runs reflecting different deductible or corridor options in the renewal package? Options: Yes - multiple deductible/corridor scenarios, No - single recommended scenario

Offer multi‑year rate guarantees and rate caps

• Which multi-year term lengths are you considering for rate guarantees (select all that apply)? Options: 2 years, 3 years, 5 years, Other - specify
• What maximum annual rate increase cap would you require as a condition of renewal guarantees (enter percentage)?
• Which triggers would void or re-open the guaranteed rate (select all that apply)? Options: Large claim > specified threshold, Change in enrollment > X%, Regulatory change impacting benefits, None
• Who on your team will negotiate multi-year guarantee language and who has authority to sign (role/title)?
• Are there any fixed-term constraints we should not alter (for example: required minimum or maximum term stated by your procurement)? Options: Standard multi-year minimum is acceptable, Need exception to standard minimum

• Master Policy Agreement
• Policy Schedule (Coverage & Attachments)
• Premium & Billing Schedule
• Laser & Known Claimant Addendum
• Rate Cap and Multi-Year Guarantee Rider
• Terminal Liability and Run-out Addendum
• Claims Reimbursement SLA
• TPA Data Exchange & Integration Addendum
• HIPAA Business Associate Addendum (BAA) — conditional
• Policy Acceptance and Signature Page

• Go-live Health Check (week 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate Decision (around day 90)
• Quarterly Policy Performance Review (ongoing)

• Update the SLA remediation plan and confirm expected resolution dates for all critical tickets.
• Prepare a one-page readiness summary that maps required evidence to the acceptance-gate checklist.
• Restate acceptance criteria and numeric targets
• Produce a documented pass/fail decision for each acceptance criterion recorded in Policy Scope.
• For any failed criteria, capture a remediation plan with dates and acceptance-validation evidence.
• Ensure the buyer owner records the formal acceptance decision in the shared workspace.
• Publish the acceptance decision, outcome data, and evidence package to the shared workspace for buyer confirmation.
• Document remediation tasks for failed criteria with targeted completion dates and required validation artifacts.
• Schedule a re-evaluation meeting if any criterion requires remediation beyond the agreed window.
• Review quarterly performance trends
• Verify quarterly trends for the named metrics and identify any deviations requiring remediation.
• Prioritize top operational enhancement requests and schedule technical impact assessments.
• Ensure all SLA breaches and critical tickets have assigned remediation dates.
• Deliver the quarterly claims performance pack including trend charts, reconciliation results, and open-ticket register.
• Prioritize the top three enhancement requests and produce a technical impact assessment within 30 days.
• Re-confirm agreed success criteria and ownership
• Confirm the deployment completed and core integrations are operational.
• Identify and document all critical blockers with agreed remediation steps and dates.
• Verify primary users have access and can perform core claims workflows.
• Run and validate three end-to-end claims reimbursement tests and publish results to the shared workspace.
• Resolve any TPA data-feed failures and confirm a successful feed for 72 continuous hours.
• Deliver an onboarding completion checklist showing active users and access gaps for remediation.
• Present first-period outcome data
• Establish whether the two tracked metrics are trending toward the targets and document the magnitude of any gaps.
• Agree specific remediation actions with completion dates to address the top 2 root causes.
• Confirm the acceptance-gate timeline and required evidence to be presented at the day-90 review.
• Produce a claims variance report listing claims where reimbursement differs from expected policy terms, including dollar impact and root-cause notes.
• Implement fixes to any TPA feed errors and report the integration success rate reaching the committed threshold for the next measurement window.
• Present outcome data against each criterion
• Review claims payment exceptions and open tickets
• Deployment and integration validation
• Diagnose variance and root causes
• Document pass/fail per criterion and decision rationale
• User onboarding and access checks
• Capture and prioritize enhancement requests
• Review lasered-member treatment and early terminal liability signals
• Early operational signals
• Agree corrective actions and timeline to acceptance gate
• Operational SLA and integration health
• Agree remediation plan for any failed criteria
• Blockers, open issues, and immediate remediation
• Record the documented acceptance decision
• Action-item review and close-out