| Administrative Data |
The QHP Application requires submission of certain administrative data that will be utilized for operational purposes. This information includes identifying information and contact information. |
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| Go to cell B1 for instructions |
Some of this information will be pre-populated based on the information you have previously entered in HIOS. |
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All fields marked with an asterik (*) are required. Depending on the Proposed Exchange Market Coverage selected, certain additional fields may be required. |
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On validation, missing or incorrect data is highlighted. |
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To validate the template, use the Validate button or press Ctrl + Shift + V. To finalize the template, press the finalize button or press Ctrl + Shift + F. |
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| Issuer ID:* |
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Proposed Exchange Market Coverage:* |
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| Issuer State:* |
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Current Sales Market:* |
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| 1. Administrative Data |
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| Company Legal Name:* |
Issuer Legal Name:* |
Issuer Marketing Name:* |
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| Associated Health Plan ID: |
TIN:* |
NAIC Company Code: |
NAIC Group Code: |
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| 2. Company Address |
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| Address:* |
Address 2 (optional): |
City:* |
State:* |
Zip Code:* |
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| 3a. Issuer Address |
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| Address:* |
Address 2 (optional): |
City:* |
State:* |
Zip Code:* |
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| 3b. Issuer Billing Address |
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| Address:* |
Address 2 (optional): |
City:* |
State:* |
Zip Code:* |
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| 4. Select Your Primary Contact:* |
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| 5. Issuer Individual Market Contact |
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| First Name: |
Last Name: |
E-mail Address: |
Phone Number: |
Phone Extension: |
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| 6. Issuer SHOP (Small Group) Contact |
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| First Name: |
Last Name: |
E-mail Address: |
Phone Number: |
Phone Extension: |
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| 7. CEO |
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| First Name:* |
Last Name:* |
E-mail Address:* |
Phone Number:* |
Phone Extension: |
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| 8. CFO |
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| First Name:* |
Last Name:* |
E-mail Address:* |
Phone Number:* |
Phone Extension: |
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| 9. Customer Service - Individual Market |
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| Customer Service Phone: |
Customer Service Phone Extension: |
Customer Service Toll Free: |
Customer Service TTY: |
Customer Service URL: |
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| 10. Customer Service - SHOP (Small Group) |
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| Customer Service Phone: |
Customer Service Phone Extension: |
Customer Service Toll Free: |
Customer Service TTY: |
Customer Service URL: |
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| 11. Contacts |
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| Contact Type |
First Name |
Last Name |
Phone Number |
Extension |
E-mail Address |
| Enrollment Contact |
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| Online Enrollment Center Contact (Primary) |
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| Online Enrollment Center Contact (Backup) |
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| System Contact |
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| Appeals/Grievances Contact |
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| Customer Service Operations Contact |
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| User Access Contact |
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| Backup User Access Contact |
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| Marketing Contact |
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| Medical Director |
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| Chief Dental Director |
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| Pharmacy Benefit Manager |
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| Government Relations Contact |
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| HIPAA Security Officer |
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| Complaints Tracking Contact |
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| Quality Contact |
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| Compliance Officer |
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| Payment Contact |
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| APTC/CSR Contact |
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| Financial Reporting Contact |
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| Financial Transfers Contact |
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| Risk Corridors Contact |
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| Risk Adjustment Contact |
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| Reinsurance Contact |
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| 12. Third Party Administrator(s): |
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| Do you have a TPA for the following processes: |
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| Enrollment* |
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| Claims Processing* |
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| Edge Server Host* |
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