CMS-10320.HIOS Data Entry Form

CMS-10320.HIOS Data Entry Form (5-16-11).xls

Health Care Reform Insurance Web Portal and Supporting Authority Contained in Sections 1103 and 10102 of The Patient Protection and Affordability Care Act, P.L. 111-148 (PPACA)

CMS-10320.HIOS Data Entry Form

OMB: 0938-1086

Document [xlsx]
Download: xlsx | pdf

Overview

Issuer General Info
Product Info
Geographic Coverage


Sheet 1: Issuer General Info

Worksheet 1 - Issuer General Information OMB Control Number: 0938-1086

1. Corporate Information








Issuer Legal Name:
State:
Issuer ID:




Federal EIN:
Market Coverage:
Issuer Marketing Name:




NAIC Company Code
NAIC Group Code:
















2. Address








Address Line 1:








Address Line 2:








City:








State:








Zip:
4 digit:
















3. Individual and Small Group Market








1). Do you offer Individual market?








2). Enter the web address for the Individual Market website if Yes is entered in C15.








3). Do you offer Small Group market?








4). Enter the web address for the Small Group Market website if Yes is entered in C17.


















4a. Customer Service Contact – Individual Market



4b. Customer Service Contact – Small Group Market



Local Number:
Extension:

Local Number:
Extension:

Toll Free Number



Toll Free Number



TTY:



TTY:



Website Address



Website Address













5. Data Submission Contact - Individual Market








Primary Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















Backup Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















6. Issuer Data Submission Validation Contact - Individual Market





Primary Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















Backup Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















7. Data Submission Contact - Small Group Market








Primary Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















Backup Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















8. Issuer Data Submission Validation Contact - Small Group Market





Primary Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















Backup Contact








First Name:
Last Name:






Phone Number:
Extension:






Email:


















9. Ratings- Individual Market








Is Issuer rated by any rating company?






Rating Company (rated in the past 2 years) Rating Type Rating Rating Company Other/Describe Rating Type Other/Describe
































































10. Ratings- Small Group Market








Is Issuer rated by any rating company?






Rating Company (rated in the past 2 years) Rating Type Rating Rating Company Other/Describe Rating Type Other/Describe










































































PRA Disclosure Statement








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 for this information collection is 0938-1086. The time required to complete this information collection is estimated to average ( 30.32 hours) or




(1,819.2 minutes) per response, 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.
"












Sheet 2: Product Info

Worksheet 2 - Product Information



Please enter applications, denials and up-rates that occurred in: Q1-2011 (Jan. 1 - Mar. 31, 2011)
OMB Control Number: 0938-1086





Cross Reference Product ID Product Name Enrollment Code/Group Number Product Type Other Product Type Description Association Product? Product Enrollment Individual or Small Group Website Address (Benefit at a Glance) Website Address (Formulary) Website Address
(Provider URL)
Enter "indemnity" if none
Covers Whole State? Number of Applications Received Number of Applications Denied Number of Up-Rated Offers SERFF-Number Open or Closed? Closed Reason Other Closed Reason Grandfathered Product?
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Sheet 3: Geographic Coverage

Worksheet 3 - Geographic Coverage (Required if product does not cover whole State)






OMB Control Number: 0938-1086
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File Typeapplication/vnd.ms-excel
File TitleIssuer Data Entry Form.xls
SubjectHealth Insurance Oversight
AuthorOCIIO
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File Modified2011-05-16
File Created2010-04-15

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