Form CMS-10321 ERRP Application

OMB Approval # INSERT NUMBER

ERRP

Early Retiree Reinsurance Program

Information Collection

U.S. Department of Health and Human Services

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is INSERT NUMBER. The time required to complete this information collection is estimated to average 227 hours for a sponsor’s first year in the program, and 150 hours for subsequent years, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

HHS Form # INSERT NUMBER

Application Information

An asterisk (*) identifies a required field.

PART I: Plan Sponsor and Key Personnel Information

A. Plan Sponsor Account Registration

1) *Organization’s Name (Must correspond with the information associated with the Federal Employer Tax Identification Number (EIN): ________________________________________________________________

2) *Type of Organization (Check one):

____ Government

____ Union

____ Religious

____ Commercial

____ Non-profit

3) *Organization’s Employer Identification Number (EIN): ______________________

4) *Organization’s Telephone Number: ext.__________

5) Organization’s FAX Number _______________________

6) *Organization’s Address (must be the address associated with the EIN provided above):

* Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

7) Organization’s Website Address:___________________________________________________

B. Authorized Representative Invitation

1)*Email Address: ____________________

2)*First Name ____________ Middle Initial (optional): _____ *Last Name ____________________

C. Authorized Representative Information

1)*Check box to agree that the Account Manager listed is associated with this Plan Sponsor

2)*Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

3) *First Name: _______________ Middle Initial (optional): _____ *Last Name: ______________

4) *Job Title: ______________________________________

5) *Date of Birth(Month/Day/Year):_____________________

6) *Social Security Number: _______________

7) *Email Address: _______________________________________________

8 *Telephone Number: _____________________ext__________

9) FAX Number:__________________

10) *Employer Name: ______________________________________________

11) * Authorized Representative Business Address:

* Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

12) *Login Information

*Login ID: ________________________________________

*Password: _______________________________________

*Security Question 1: _______________________________

*Answer 1: _______________________________________

*Security Question 2: ______________________________

*Answer 2: _______________________________________

D. Account Manager Information

1)*Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

2) *First Name: _______________ Middle Initial (optional): _____ *Last Name: ______________

3) *Job Title: ______________________________________

4) *Date of Birth(Month/Day/Year):_____________________

5) *Social Security Number: _______________

6) *Email Address: _______________________________________________

7) *Telephone Number: _____________________ext__________

8) FAX Number:__________________

9) *Employer Name: ________________________________________

10) *Account Manager Business Address:

* Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

11) Login Information

*Login ID: ________________________________________

*Password: _______________________________________

*Security Question 1: _______________________________

*Answer 1: _______________________________________

*Security Question 2: _______________________________

*Answer 2: _______________________________________

E. Designee Invitation

1)*Email Address:____________________

2)*First Name: ____________ Middle Initial (optional): _____ *Last Name: __________________

3)*Pass Phrase: ___________________

4)* Please indicate the actions that the designee can perform for this application

F. Designee Information

1) *Enter the Pass-phrase: ____________________________

2)*Read and accept the User Agreement and Privacy Policy (located in Part I Section G of this document)

3) *First Name: _______________ Middle Initial (optional):____ *Last Name:_________________

4) *Job Title: __________________________

5) *Employer Name: ____________________________

6) *Date of Birth (Month/Day/Year): ______________

7) *Social Security Number: ________________

8) *Email Address: __________________________________

9) *Telephone Number: ____________________ext.___________

10) FAX Number :________________

11)*Address:

* Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

12) Login Information

*Login ID: ________________________________________

*Password: _______________________________________

*Security Question 1: _______________________________

*Answer 1: _______________________________________

*Security Question 2: _______________________________

*Answer 2: _______________________________________

G. User Agreement and Privacy Policy

THE FOLLOWING DESCRIBES THE TERMS AND CONDITIONS ON WHICH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) OFFERS YOU ACCESS TO HHS’’ EARLY RETIREE REINSURANCE PROGRAM (ERRP) SECURE WEB SITE.

You must read and accept the terms and conditions contained in this User Agreement expressly set out below and incorporated by reference before you may access the ERRP Secure Web Site. HHS may amend this User Agreement at any time. Except as stated below, all amended terms shall automatically be effective 30 days after they are initially posted on the Site. This User Agreement is effective immediately.

1. Purpose of the ERRP Secure Web Site

The ERRP Secure Web Site provides Plan Sponsors with the resources required to become a participant in the Early Retiree Reinsurance Program described in Section 1102 of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), and regulations at 45 CFR Part149.

2. Privacy Policy

HHS, of which the ERRP Secure Web Site is a part, has a clear privacy policy. When you access the ERRP Secure Web Site, we collect the minimum amount of information about you necessary to process your application for the Early Retiree Reinsurance Program and to manage your account.

3. Information Automatically Collected and Stored

When you browse through any web site, certain personal information about you can be collected. We automatically collect and temporarily store the following information about your visit:

• the name of the domain you use to access the Internet (for example, serviceprovider.com, where “serviceprovider” would be the name of the entity providing your access to the Internet)

• the date and time of your visit

• the pages you visited

• the address of the web site you came from when you came to visit.

This information is used for statistical purposes only and to help us make this site more useful to visitors. Unless it is specifically stated otherwise, no additional information will be collected about you.

4. Information Collected to Process Applications and Manage Accounts Through the ERRP Secure Web Site

When you apply for the ERRP through the ERRP Secure Web Site, HHS will collect personal information necessary to validate participants, and to process and manage the application. The authority to collect this information is granted by §1102 of PPACA (P.L. 111-148) and HHS ERRP implementing regulations at 45 CFR Part 149 as well as the Debt Collection Improvement Act of 1996 at 31 U.S.C. §7701(c) and the Federal Privacy Act at 5 U.S.C. §552a. This may include your name, address, telephone and fax numbers, Email address, social security number, drivers license photocopy, Federal Employer Identification Number (EIN), banking information, or other reimbursement information. Provision of this information is mandatory for participation in the ERRP. HHS may also collect a password and password hint for each participant accessing the ERRP Secure Web Site. We use this information to verify participants' identities in order to prevent unauthorized access to secure ERRP Secure Web Site accounts.

HHS staff has role-based access to this information, and use only the information minimally necessary to accomplish their jobs.

The personal information you provide is encrypted and sent to HHS using a secure method, in order to assure that your personal information is securely and safely transmitted. However, no one can give an absolute assurance that information intended to be maintained as private, whether transmitted via the Internet or otherwise, cannot be accessed inappropriately or unlawfully by third parties. HHS has taken and will continue to take reasonable steps to ensure the secure and safe transmission of your personal information.

5. Personally Provided Information

If you are not involved with the submission or management of an ERRP application on the ERRP Secure Web Site, you do not have to give HHS personal information. If you choose to provide HHS with additional information about yourself through Email, forms, surveys, etc., HHS will maintain the information as long as needed to respond to your question or to fulfill the stated purpose of the communication.

6. Disclosure

HHS does not disclose, give, sell or transfer any personal information about its visitors, unless required for law enforcement or statute.

7. Intrusion Detection

The ERRP Web Sites are maintained by the U.S. Government and are protected by various provisions of Title 18, U.S. Code. Violations of Title 18 are subject to criminal prosecution in Federal court.

For site security purposes and to ensure that this service remains available to all participants, we employ software programs to monitor traffic to identify unauthorized attempts to upload or change information, or otherwise cause damage. In the event of authorized law enforcement investigations, and pursuant to any required legal process, information from these sources may be used to help identify an individual.

8. Systems of Records

Information originally collected in traditional paper systems can be submitted electronically, i.e., electronic commerce transactions and information updates about eligibility benefits. Electronically submitted information is maintained and destroyed pursuant to the Federal Records Act and in some cases may be subject to the Privacy Act. If information that you submit is to be used in a Privacy Act system of records, there will be a Privacy Act Notice provided.

9. Links

References from ERRP web sites to any non-governmental entity, product, service or information do not imply endorsement or recommendation by HHS or any other HHS agency or employees.

We are not responsible for the contents of any "off-site" web pages referenced from this server. We do not endorse ANY specific products or services provided by public or private organizations. In addition, we do not necessarily endorse the views expressed by such sites, nor do we warrant the validity of any site's information or its fitness for any particular purpose.

10. Pop-up Advertisements

When visiting ERRP web sites, your web browser may produce pop-up advertisements. These advertisements were most likely produced by other web sites you visited or by third party software installed on your computer. HHS does not endorse or recommend products or services for which you may view a pop-up advertisement on your computer screen while visiting our site.

11. Outdated Information

Many HHS documents are time sensitive. Department policies change over time. Information in older documents may be outdated. You also may wish to review our Privacy Policy in section 2.

12. Accessibility

This page provides information for those visitors who use assistive or other devices to access the content on the ERRP web sites. Please see Contact Us at if you have general questions and comments or have difficulty finding something on this site.

13. Synopsis of Section 508 Accessibility Requirements

HHS is committed to making all ERRP Web Sites accessible to the widest possible audience, including individuals with disabilities. In keeping with its mission, HHS complies with the regulations of Section 508 of the Rehabilitation Act and the HHS Section 508 Implementation Policy. The information contained within the ERRP Web Sites is intended to be accessible through screen readers and other accessibility tools. If alternative means of access to any information contained on ERRP Web Sites are needed, or interpreting any information proves difficult, please contact the ERRP Contact Center via telephone or Email. In an Email, please indicate the nature of the accessibility problem including the accessibility tool and web browser used, the web page address that is causing difficulty, contact name, Email address, and phone number. Please do not include any Protected Health Information (PHI), as defined in the Health Insurance Portability and Accountability Act (HIPAA), in the Email.

14. Freedom of Information Act (FOIA)

The ERRP Web Sites are a service of HHS. Any Freedom of Information Act (FOIA) requests concerning the ERRP Web Sites should be submitted in accordance with the Department's FOIA guidelines. Information on making FOIA requests is available at the Freedom of Information Group page at http://www.hhs.gov/foia/. You also may wish to review our Privacy Policy in Section 2.

PART II: Plan Information

A. Plan Information

1) *Plan Name:

2) *Plan Year Cycle: Start Month/Day:__________ End Month/Day: ____________

B. Benefit Option(s) Provided Under This Plan

1a) *Benefit Option Name: _________________________________

1b) *Unique Benefit Option Identifier: _________________________

1c) *Benefit Option Type: Self-Funded __________ Insured __________ Both __________

1d) *Benefit Administrator Company Name: _________________________________________

C. *Programs and Procedures for Chronic and High-Cost Conditions

Please identify the chronic and high-cost conditions for which the employment-based plan has implemented programs and procedures to generate cost savings with respect to participants with those conditions. Please summarize the programs and procedures.

D. *Estimated Amount of Early Retiree Reinsurance Program Reimbursements

Please estimate the projected amount of proceeds you expect to receive under the Early Retiree Reinsurance Program for the plan identified in this application, for each of the first two plan year cycles identified in this application. For this purpose only, please assume for each of those plan year cycles that there will be sufficient program funds to cover all claims submitted by the Plan Sponsor that comply with program requirements, although this might not be the case.

E. *Intended Use of Early Retiree Reinsurance Program Reimbursements

1. *Please summarize how your organization will use proceeds under the Early Retiree Reinsurance Program to reduce health benefit or health benefit premium costs for the sponsor of the employment-based plan, or reduce premium contributions, copayments, deductibles, coinsurance, or other out-of-pocket costs (or combination of these) for plan participants.

2. *Please summarize how the Plan Sponsor will use program reimbursement to maintain its level of financial contribution to the employment-based plan.

PART III: Banking Information for Electronic Funds Transfer

1) *Bank Name: ___________________________________

2) *Bank Address:

*Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

3) *Account Number: ____________________________

4) *Name of Organization Associated with Account: ________________________________________

5) *Account type: (Checking or Savings Account) _______________

6) *Bank Routing Number: ____________________

7) *Bank Contact First Name: _______________ Middle Initial (optional): ____ *Last Name: _________________

8) *Email address: _______________________________________________

9) *Telephone Number: ____________________

PART IV. Plan Sponsor Agreement
1.	Compliance: In order to receive program reimbursement(s), Plan Sponsor agrees to comply with all of the terms and conditions of Section 1102 of the Patient Protection Act (P.L. 111-148)and 45 CFR Part 149 and in other guidance issued by HHS, including, but not limited to, the conditions for submission of data for obtaining reimbursement and the record retention requirements.
2.	Reimbursement-Related and Other Representations Made by Designees: Plan Sponsor certifies that all individuals identified as Designees in this Application, including, but not limited to, Reimbursement Requesters, have been given authority by the Plan Sponsor to perform those respective functions on behalf of the Plan Sponsor. Plan Sponsor understands that it is bound by any representations such individuals make with respect to the Sponsor’s involvement in the Early Retiree Reinsurance program, including but not limited to the Sponsor’s application for, participation in, and reimbursement under, the Program.
3.	Written Agreement: Plan Sponsor certifies that, prior to submitting a Reimbursement Request, it has executed a written agreement with its health insurance issuer or group health plan regarding disclosure of information to HHS, and the issuer or plan agrees to disclose to HHS, on behalf of the Plan Sponsor, the information necessary for the Plan Sponsor to comply with the requirements of the Early Retiree Reinsurance Program.
4.	Use of Records: Plan Sponsor understands and agrees that officers, employees and contractors of the Department of Health and Human Services may use data and information collected under the Early Retiree Reinsurance Program only for the purposes of, and to the extent necessary in, carrying out their responsibilities under Section 1102 of the Patient Protection Act (P.L. 111-148)and 45 CFR Part 149 including, but not limited to, determination of reimbursements and reimbursement-related oversight and program integrity activities, or as otherwise required by law. Nothing in this section limits the Office of Inspector General’s (OIG) authority to fulfill the OIG’s responsibilities in accordance with applicable Federal law.
5.	Obtaining Federal Funds: Plan Sponsor acknowledges that the information furnished in its Plan Sponsor application is being provided to obtain Federal funds. Plan Sponsor certifies that it requires all subcontractors, including plan administrators, to acknowledge that information provided in connection with the subcontract is used for purposes of obtaining Federal funds. Plan Sponsor acknowledges that reimbursement of program funds is conditioned on the submission of accurate information. Plan Sponsor agrees that it will not knowingly present or cause to be presented a false or fraudulent claim. Plan Sponsor acknowledges that any excess reimbursement made to the Plan Sponsor under the Early Retiree Reinsurance Program, or any debt that arises from such excess reimbursement, may be recovered by HHS. Plan Sponsor will promptly update any changes to the information submitted in its Plan Sponsor application. If Plan Sponsor becomes aware that information in this application is not (or is no longer) true, accurate and complete, Plan Sponsor agrees to notify HHS promptly of this fact.
6.	Data Security: Plan Sponsor agrees to establish and implement proper safeguards against unauthorized use and disclosure of the data exchanged under this Plan Sponsor application. Plan Sponsor recognizes that the use and disclosure of protected health information (PHI) is governed by the Health Insurance Portability and Accountability Act (HIPAA) and accompanying regulations. Plan Sponsor certifies that its employment-based plan(s) has established and implemented appropriate safeguards in compliance with 45 CFR Parts 160, 162 and 164 (HIPAA administrative simplification, privacy and security rule) in order to prevent unauthorized disclosure of such information or data. Sponsor also agrees that if it participates in the administration of the plan(s), then it has also established and implemented the same safeguards in compliance with the above HIPAA citations. Any and all Plan Sponsor personnel interacting with PHI shall be advised of (1) the confidential nature of the information; (2) safeguards required to protect the information, and (3) the administrative, civil and criminal penalties for noncompliance contained in applicable Federal laws.
7.	Depository Information: Plan Sponsor hereby authorizes HHS to initiate reimbursement, credit entries and other adjustments, including offsets and requests for reimbursement, in accordance with the provisions of Section 1102 of the Patient Protection Act (P.L. 111-148) and 45 CFR Part 149 and applicable provisions of 45 CFR Part 30, to the account at the financial institution (hereinafter the “Depository”) indicated under the Electronic Funds Transfer (EFT) section of the Plan Sponsor application. Plan Sponsor agrees to immediately pay back any excess reimbursement or debt upon notification from HHS of the excess reimbursement or debt. Plan Sponsor agrees to promptly update any changes in its Depository information.
8.	Change of Ownership: The Plan Sponsor shall provide written notice to HHS at least 60 days prior to a change in ownership, as defined in 45 CFR Part 149. When a change of ownership results in a transfer of the liability for health benefits costs, this Plan Sponsor Agreement is automatically assigned to the new owner, who shall be subject to the terms and conditions of this Plan Sponsor Agreement.
	Signature of Plan Sponsor Authorized Representative I, the undersigned Authorized Representative of Plan Sponsor, declare that I have legal authority to sign and bind the Plan Sponsor to the terms of this Plan Sponsor Agreement, and I have or will provide evidence of such authority. I declare that I have examined this Plan Sponsor Application and Plan Sponsor Agreement. My signature legally and financially binds the Plan Sponsor to the laws, regulations, and other guidance applicable to the Early Retiree Reinsurance Program (including, but not limited to Section 1102 of the Patient Protection Act (P.L. 111-148) and 45 CFR Part 149 and applicable provisions of 45 CFR Part 30 and all other applicable laws and regulations. I certify that the information contained in this Plan Sponsor Application and Plan Sponsor Agreement is true, accurate and complete to the best of my knowledge and belief, and I authorize HHS to verify this information. I understand that, because program reimbursement will be made from Federal funds, any false statements, documents, or concealment of a material fact is subject to prosecution under applicable Federal and/or State law. Electronic Signature

Reimbursement Request Information

An asterisk (*) identifies a required field.

PART I: Reimbursement Request Setup Information

A. Early Retiree List : Submission Information

Note: The Plan Sponsor must provide the following information for each benefit option. These fields may be applied to multiple benefit options or may be filled in for each benefit option individually.

1) * Early Retiree List Submission Method (Choose one):

____ Secure file upload using Hypertext Transfer Protocol Secure (HTTPS) to ERRP Secure Website

____ Plan Sponsor (or Vendor) Mainframe to HHS Mainframe

____ Data entry in the ERRP Secure Website

Note: Items 2-4 are required if sending data using the mainframe-to-mainframe method. If a Plan Sponsor chooses this method, it must work with HHS to establish mainframe communications protocols.

2)*Mainframe Vendor ID (assigned by HHS): ________________

3)*Name of Organization Submitting Early Retiree Data: ___________________________________

4)*Contact Information:

4a)*First Name: ___________ Middle Initial (optional): _____*Last Name: __________________

4b)*Email Address: _____________________________________________________

4c)*Telephone Number: _____________________ext__________

4d) FAX Number: _______________________

4e)* Address:

*Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

B. Documentation of Actual Plan Costs: Submission Information

Note: The Plan Sponsor must provide the following information for each benefit option. These fields may be applied to multiple benefit options or may be filled in for each benefit option individually.

1) *Documentation of Actual Plan Costs: Submission Method (Choose one):

____ Secure file upload using Hypertext Transfer Protocol Secure (HTTPS) to ERRP Secure Website

____ Plan Sponsor (or Vendor) Mainframe to HHS Mainframe

____ Data entry in the ERRP Secure Website

____ Submit hardcopy information via mail delivery service

Note: Items 2-4, as applicable, are required if sending data using the mainframe-to-mainframe or hardcopy method of delivery. If a Plan Sponsor chooses the mainframe to mainframe method, it must work with HHS to establish mainframe communications protocols.

2)*Mainframe Vendor ID (assigned by HHS): ________________

3)*Name of Organization Submitting Claims Data: ___________________________________

4)*Contact Information:

4a)*First Name: ___________ Middle Initial (optional): _____*Last Name: __________________

4b)*Email Address: _____________________________________________________

4c)*Telephone Number: _____________________ext__________

4d) FAX Number: _______________________

4e)* Address:

*Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

C. Documentation of Actual Early Retiree Costs: Submission Information

Note: The Plan Sponsor must provide the following information for each benefit option. These fields may be applied to multiple benefit options or may be filled in for each benefit option individually.

1) *Documentation of Actual Early Retiree Costs: Submission Method (Choose one):

____ Secure file upload using Hypertext Transfer Protocol Secure (HTTPS) to ERRP Secure Website

____ Submit hardcopy information via mail delivery service

Note: Items 2 and 3 are required if submitting hardcopy information via mail delivery service.

2)*Name of Organization Submitting Early Retiree Data: ___________________________________

3)* Contact Information:

3a)*First Name: ___________ Middle Initial (optional): _____*Last Name: __________________

3b)*Email Address: _____________________________________________________

3c)*Telephone Number: _____________________ext__________

3d) FAX Number: _______________________

3e)* Address:

*Street Line 1: ___________________________________

Street Line 2: ____________________________________

*City: ______________________

*State/US Territory: _________________________

*Zip Code: ____________________________

PART II: Reimbursement Request Information

A. Initiate Reimbursement Request

A Plan Sponsor must initiate an electronic Reimbursement Request and provide the following data elements:

1. *Reimbursement Requester’s Name (First Name, Middle Initial, Last Name)

2. *Reimbursement Requester’s Email Address

3. *Reimbursement Requester’s Phone Number

4. *Plan Sponsor ID (assigned by HHS)

5. *Application ID (assigned by HHS)

6. *Unique Benefit Option Identifier(s) for which Plan Sponsor is seeking reimbursement

B. Submit List of Early Retirees

A Plan Sponsor must submit with each Reimbursement Request an electronic list of Early Retirees for whom it is seeking program reimbursement. For each Early Retiree List, the following data elements must be provided:

1. *Reimbursement Request Number (assigned by HHS)

2. *Early Retiree List Submitter’s Name (*First Name, Middle Initial, *Last Name)

3. *Early Retiree List Submitter’s Email Address

4. *Early Retiree List Submitter’s Phone Number

5. *Vendor ID (if applicable)

6. *Plan Sponsor ID (assigned by HHS)

7. *Application ID (assigned by HHS)

8. *Unique Benefit Option Identifier

For each Early Retiree:

9. *First Name

10. *Last Name

11. Middle initial

12. *Social Security Number (SSN)

13. *Date of Birth

14. *Gender

15. *Relationship to the Early Retiree (self, spouse, surviving spouse, dependent)

16. *Effective Date – This should be either the first day of the first Plan Year cycle for which the sponsor is applying for the program, or the first date of coverage under which the individual satisfies the definition of an Early Retiree under 45 CFR Part 149, whichever is later.

17. *Termination date –This should be the last date of coverage for the individual under the plan, or the last day the individual will satisfy the definition of an Early Retiree under 45 CFR Part 149, whichever comes first. If the former is unknown, please provide the latter.

18. *Record Type (indicates whether record is intended to Add, Update, or Delete)

a)

C. Submit Documentation of Actual Costs

A Plan Sponsor must submit with each Reimbursement Request the following data related to the Reimbursement Request and each item or service for which the Plan Sponsor is seeking program reimbursement:

1. *Reimbursement Request Number (assigned by HHS)

2. * Reimbursement Requester’s Name (*First Name, Middle Initial, *Last Name)

3. *Reimbursement Requester’s Email Address

4. * Reimbursement Requester’s Phone Number

5. *Vendor ID (if applicable)

6. *Plan Sponsor ID (assigned by HHS)

7. *Application ID (assigned by HHS)

8. *Unique Benefit Option Identifier

For each item or service for which the Plan Sponsor is seeking program reimbursement:

9. *First Name

10. *Last Name

11. Middle Initial

12. *Social Security Number (SSN)

13. *Incurred Date

14. *Plan Paid Date

15. *Plan Paid Amount

16. *Early Retiree Paid Date

17. *Early Retiree Paid Amount

18. *Health Benefit Item or Service Description

19. *Record Type (indicates whether record is intended to Add, Update, or Delete)

D. Submit Early Retiree Paid Claims Receipt or Other Evidence

A Plan Sponsor must submit an Early Retiree Paid Claims Receipt or other evidence of payment for each item or service for which it is seeking program reimbursement for amounts that the Early Retiree paid.

Appeal Information

An asterisk (*) identifies a required field.

A Plan Sponsor must submit the following information if it wishes to appeal a reimbursement determination:

1. *Plan Sponsor ID (assigned by HHS)

2. *Application ID (assigned by HHS)

3. *Determination being appealed

4. *Reason(s) for disagreement with determination

5. *Will additional documentary evidence be sent using mail delivery service? (Choose Yes or No)

6. *Estimated date by which the documentary evidence will be received

If Plan Sponsor answered Yes to #5:

7. *Additional Documentary Evidence

Reporting Data Inaccuracies

An asterisk (*) identifies a required field.

A Plan Sponsor must submit the following information when reporting data inaccuracies:

1. *Plan Sponsor ID (assigned by HHS)

2. *Application number (assigned by HHS)

3. *Information necessary for HHS to understand the nature of and magnitude of the data inaccuracy

Reporting Change of Ownership

An asterisk (*) identifies a required field.

A Plan Sponsor must report the following information when reporting a Change of Ownership:

*Information necessary for HHS to understand the transaction and structure of the ownership change.

Other Information to be Produced Upon Request

1. *Fraud, Waste, and Abuse (FWA) Policies and Procedures related to the ERRP

2. *Data demonstrating the effectiveness of the FWA Policies and Procedures

3. *Written agreement with its health insurance issuer (as defined in 45 CFR Section 160.103) or group health plan regarding disclosure of information to HHS

4. *Any other documentation or data necessary for the Secretary to effectively administer the ERRP.