CMS-10433 Appendix A 1 Issuer data elements

Appendix A.1 - QHP Issuer Application Data Requirements
The following appendix lays out the data elements that will be collected through the QHP Issuer
section of the QHP Issuer certification application process. The data collected for QHP
certification, ongoing QHP oversight, financial management, and eligibility and enrollment
functions (including the Exchange website) are reflected in the categories identified below.
Administrative Data Elements
The section requests that issuers provide basic information required to identify issuers and the
Exchange markets they intend to serve, and to facilitate communications with and payment to
issuers. Data will be pre-populated from HIOS or other templates whenever possible.
Issuer Data
1. HIOS Issuer ID
2. HIOS Company ID
3. Associated HPID
4. State
5. Proposed Exchange Market Coverage
6. Current Sales Market
7. Company Legal Name
8. TIN
9. Not-for-Profit
10. NAIC Company Code
11. NAIC Group Code
12. Name of Holding Company
13. Legal Name
14. Marketing Name
15. Company Address: Address
16. Company Address: Address 2
17. Company Address: City
18. Company Address: State
19. Company Address: Zip Code
20. Issuer Address
21. Issuer Address 2
22. Issuer City
23. Issuer State
24. Issuer Zip Code
Contacts
1. Main Company Contact: First Name
2. Main Company Contact: Last Name
3. Main Contact: E-mail Address
4. Main Company Contact: Phone Number
5. Main Company Contact: Phone Ext
6. CEO First Name
7. CEO Last Name
8. CEO E-mail Address
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9. CEO Phone Number
10. CEO Phone Ext
11. CFO First Name
12. CFO Last Name
13. CFO E-mail Address
14. CFO Phone Number
15. CFO Phone Ext
16. Customer Service Phone - Individual Market
17. Customer Service Phone Ext - Individual Market
18. Customer Service Toll Free - Individual Market
19. Customer Service TTY - Individual Market
20. Customer Service URL - Individual Market
21. Customer Service Phone - SHOP
22. Customer Service Phone Ext - SHOP
23. Customer Service Toll Free - SHOP
24. Customer Service TTY - SHOP
25. Customer Service URL - SHOP
26. Compliance Officer - First Name
27. Compliance Officer - Last Name
28. Compliance Officer - Phone Number
29. Compliance Officer - Phone Number Ext
30. Compliance Officer - Email
31. Enrollment Contact - First Name
32. Enrollment Contact - Last Name
33. Enrollment Contact - Phone Number
34. Enrollment Contact - Phone Number Ext
35. Enrollment Contact - Email
36. Online Enrollment Center Contact (Primary) - First Name
37. Online Enrollment Center Contact (Primary) - Last Name
38. Online Enrollment Center Contact (Primary) - Phone Number
39. Online Enrollment Center Contact (Primary) - Phone Number Ext
40. Online Enrollment Center Contact (Primary) - Email
41. Online Enrollment Center Contact (Backup) - First Name
42. Online Enrollment Center Contact (Backup) - Last Name
43. Online Enrollment Center Contact (Backup) - Phone Number
44. Online Enrollment Center Contact (Backup) - Phone Number Ext
45. Online Enrollment Center Contact (Backup) - Email
46. System Contact - First Name
47. System Contact - Last Name
48. System Contact - Phone Number
49. System Contact - Phone Number Ext
50. System Contact - Email
51. Appeals/Grievances Contact - First Name
52. Appeals/Grievances Contact - Last Name
53. Appeals/Grievances Contact - Phone Number
54. Appeals/Grievances Contact - Phone Number Ext
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55. Appeals/Grievances Contact - Email
56. Pharmacy Benefit Manager Contact - First Name
57. Pharmacy Benefit Manager Contact - Last Name
58. Pharmacy Benefit Manager Contact - Phone Number
59. Pharmacy Benefit Manager Contact - Phone Number Ext
60. Pharmacy Benefit Manager Contact - Email
61. Customer Service Operations Contact - First Name
62. Customer Service Operations Contact - Last Name
63. Customer Service Operations Contact - Phone Number
64. Customer Service Operations Contact - Phone Number Ext
65. Customer Service Operations Contact - Email
66. Marketing Contact - First Name
67. Marketing Contact - Last Name
68. Marketing Contact - Phone Number
69. Marketing Contact - Phone Number Ext
70. Marketing Contact - Email
71. Chief Medical Director - First Name
72. Chief Medical Director - Last Name
73. Chief Medical Director - Phone Number
74. Chief Medical Director - Phone Number Ext
75. Chief Medical Director - Email
76. Chief Dental Director - First Name
77. Chief Dental Director - Last Name
78. Chief Dental Director - Phone Number
79. Chief Dental Director - Phone Number Ext
80. Chief Dental Director - Email
81. Payment Contact - First Name
82. Payment Contact - Last Name
83. Payment Contact - Phone Number
84. Payment Contact - Phone Number Ext
85. Payment Contact - Email
86. Government Relations Contact - First Name
87. Government Relations Contact - Last Name
88. Government Relations Contact - Phone Number
89. Government Relations Contact - Phone Number Ext
90. Government Relations Contact - Email
91. HIPAA Security Officer - First Name
92. HIPAA Security Officer - Last Name
93. HIPAA Security Officer - Phone Number
94. HIPAA Security Officer - Phone Number Ext
95. HIPAA Security Officer - Email
96. Complaints Tracking Contact - First Name
97. Complaints Tracking Contact - Last Name
98. Complaints Tracking Contact - Phone Number
99. Complaints Tracking Contact - Phone Number Ext
100. Complaints Tracking Contact - Email
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101. Quality Contact - First Name
102. Quality Contact - Last Name
103. Quality Contact - Phone Number
104. Quality Contact - Phone Number Ext
105. Quality Contact - Email
106. Primary Contact - Individual or Small Group
107. Individual Market Contact - First Name
108. Individual Market Contact - Last Name
109. Individual Market Contact - Phone Number
110. Individual Market Contact - Phone Number Ext
111. Individual Market Contact - Email
112. SHOP Contact - First Name
113. SHOP Contact - Last Name
114. SHOP Contact - Phone Number
115. SHOP Contact - Phone Number Ext
116. SHOP Contact - Email
117. APTC/CSR Contact - First Name
118. APTC/CSR Contact - Last Name
119. APTC/CSR Contact - Phone Number
120. APTC/CSR Contact - Phone Number Ext
121. APTC/CSR Contact - Email
122. Risk Corridors Contact - First Name
123. Risk Corridors Contact - Last Name
124. Risk Corridors Contact - Phone Number
125. Risk Corridors Contact - Phone Number Ext
126. Risk Corridors Contact - Email
127. Risk Adjustment Contact - First Name
128. Risk Adjustment Contact - Last Name
129. Risk Adjustment Contact - Phone Number
130. Risk Adjustment Contact - Phone Number Ext
131. Risk Adjustment Contact - Email
132. Reinsurance Contact - First Name
133. Reinsurance Contact - Last Name
134. Reinsurance Contact - Phone Number
135. Reinsurance Contact- Phone Number Ext
136. Reinsurance Contact - Email
137. Financial Transfers Contact: First Name
138. Financial Transfers Contact: Last Name
139. Financial Transfers Contact: Phone Number
140. Financial Transfers Contact: Phone Number Ext
141. Financial Transfers Contact: Email
142. Third Party Administrator (TPA) ID
143. Third Party Administrator (TPA) Name
144. Third Party Administrator (TPA) Process
145. Third Party Administrator (TPA) Process URL/EDI Gateway Info
146. Third Party Administrator (TPA) Confirmation of Services
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147.
User Access Contact – First Name
148.
User Access Contact – Last Name
149.
User Access Contact – Phone Number
150.
User Access Contact – Phone Number Ext
151.
User Access Contact – Email
152.
Backup User Access Contact – First Name
153.
Backup User Access Contact – Last Name
154.
Backup User Access Contact – Phone Number
155.
Backup User Access Contact – Ext
156.
Backup User Access Contact – Email
157.
Financial Reporting Contact - First Name
158.
Financial Reporting Contact – Last Name
159.
Financial Reporting Contact – Phone Number
160.
Financial Reporting Contact – Phone Number Ext
161.
Financial Reporting Contact - Email
Miscellaneous
162. Do you have a TPA that currently provides services for the following processes:
Enrollment (Y/N), Claims Processing (Y/N), Edge Server (Y/N)
State Licensure Documentation
Attestations and documentation necessary to demonstrate that an issuer is licensed and has
authority to sell all applicable products in the services areas in which it intends to offer a QHP. If
license and certificate of authority are not in possession for all service areas, attestation that
license and certificate of authority will be obtained and a projected date of obtaining license.

Documentation of Good Standing
Attestations and documentation necessary to demonstrate that an issuer is in compliance with all
applicable State solvency requirements and other relevant State regulatory requirements.

Accreditation Data Elements
The section requests that issuers provide, if applicable, certain data elements about accreditation
conducted by a recognized accrediting entity. Issuer must also authorize the release of
accreditation survey data to the Exchange.
1. Accreditation Status
2. NCQA template
a. NCQA Org ID(s)
b. Accredited Market Type(s)
c. NCQA Sub ID(s)
d. Accredited Product Type(s)
e. Accreditation Status(es)
f. Product ID
g. Expiration date(s)
h. Accreditation certificate(s)
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3. URAC template
a. URAC Application number(s)
b. Accredited Market type(s)
c. Accreditation status(es)
d. Expiration date(s)
e. URAC accreditation certificate(s)
f. Product ID
4. Issuer Accreditation attestation
a. Issuers with accreditation will attest to the following statements:
1. The QHP issuer authorizes the release of its accreditation data from the
accrediting entity to the FFE (if applicable).
2. The QHP issuer understands and acknowledges that prior to 2016, the Exchange
Internet Portal may display composite data gathered using the Consumer Assessment
of Healthcare Providers and Systems CAHPS® measures, which correspond to
existing product lines outside of the Exchange. This data will be displayed if the
following conditions are met:

·
·

·

The QHP issuer has authorized the release of its accreditation data as
required for QHP certification;
CAHPS® data were considered as part of the QHP issuer’s
accreditation on Medicaid or commercial lines of business and were
submitted to the Exchange by the accrediting entity; and
CAHPS® data that were submitted to the Exchange by the accrediting
entity are available for the same product type as the QHP that is being
offered in the Exchange (e.g. HMO Adult CAHPS data for HMO
QHP; PPO Adult CAHPS® data for PPO QHP; HMO Child CAHPS®
data for Child-Only QHP HMO; PPO Child CAHPS®).

b. Issuers who indicate that they are not accredited will attest to the following
statements:
1. The QHP issuer understands and acknowledges that prior to 2016, the
Exchange Internet Portal may display composite data gathered using the
Consumer Assessment of Healthcare Providers and Systems CAHPS®
measures, which correspond to existing product lines outside the Exchange.
These data will be displayed if the following conditions are met:
·
·

·

The QHP issuer has authorized the release of its accreditation data as
required for QHP certification;
CAHPS® data were considered as part of the QHP issuer’s
accreditation on Medicaid or commercial lines of business and were
submitted to the Exchange by the accrediting entity; and
The CAHPS® data that were submitted to the Exchange by the
accrediting entity are available for the same product type as the QHP
that is being offered in the Exchange (e.g. HMO Adult CAHPS data
for HMO QHP; PPO Adult CAHPS® data for PPO QHP; HMO Child
CAHPS® data for Child-Only QHP HMO; PPO Child CAHPS®.)
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Network Adequacy Data Elements
Attestations regarding to the following to demonstrate that an issuer has an adequate range of
providers for the intended service areas:
1. Maintain a provider network that is sufficient in number and types of providers to assure
that all services are accessible without unreasonable delay, as specified in 45 CFR
156.230(a)(2);
2. The issuer’s network meets applicable State network adequacy requirements;
3. The issuer’s network reflects executed contracts for the year in which the issuer is
applying; and
4. If the issuer is applying in a State that does not have authority to conduct network
adequacy reviews consistent with 45 CFR 156.230, the issuer is accredited.
If the issuer cannot respond affirmatively to each of the attestations, the issuer would submit a
network access plan. In general, the access plan may include, but is not limited to, the following
types of information based on the NAIC Model Act requirements:
1. Standards for network composition
2. Referral policy
3. Needs of special populations
4. Health needs assessment
5. Communication with members.
6. Coordination activities
7. Continuity of care

Essential Community Provider (ECP) Data Elements
Number and type of participating Essential Community Providers participating in an issuer's
provider network and other documentation necessary to demonstrate that that an issuer has an
adequate range of ECPs for the intended service areas. For issuers qualifying for the alternate
ECP standard, the number and type of providers in the issuer’s network and other documentation
necessary to ensure access for low-income and underserved populations in the intended service
areas. Data will be pre-populated from HIOS or other templates whenever possible.
1. National Provider Number (NPN)
2. Provider Name
3. Provider Type
4. ECP Category
5. Street Address
6. City
7. State
8. Zip
9. On ECP List or Write-In?
10. Write-In Explanation
11. National Provider Number (NPI)
12. Justification for number of ECP

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Additional Supporting Documentation
Additional documentation required by the Exchange for oversight purposes such as, but not
limited to:
1. Compliance plan, in or ready for implementation, consisting of:
a. Written policies, procedures, and standards of conduct
b. designated Compliance Officer and a compliance committee
c. Compliance training and education
d. Effective lines of communication
e. Well-publicized disciplinary standards
f. A system for routine monitoring and the identification of compliance risks
g. Procedures and a system for prompt responses to compliance issues
2. Organization chart

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