Crosswalk document

CMS-10464 - Crosswalk Tool.pdf

Agent/Broker Data Collection in Federally-facilitated Health Insurance Exchanges

Crosswalk document

OMB: 0938-1204

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Appendix: Collection Tool Cross-Reference
Original Collection Tool

Revised Collection Tool
– Individual
Login ID*
Find Local Help
preference*
Password*
Business street
address*
Password confirmation* Business city*
First name*
Business state*
Middle name
Business zip code*

Revised Collection Tool
– Business Entity**
Business entity name*
Business entity street
address*
Business entity city*
Business entity state*
Business entity zip
code*
Business entity phone*

Last name*

Business phone*

Email address*

Business email address*

Email address
confirmation*
Work phone*

Business URL

Business entity email
address*
Business entity URL

National Producer
Number*

Business entity National
Producer Number*

State*

National Producer
Number confirmation*

Zip code*

Language preference*

User type*
National Producer
Number*
Organization type
Organization*
Primary language*
Region*
Time zone*
Accessibility preference
Number of records*

State(s) of licensure*

Business entity National
Producer Number
confirmation*
Business entity state(s)
of licensure*

*Required fields
**Required only for a small subset of agents/brokers

Revised Collection Tool
– Web-based Entity**
Web-based entity
name*
Web-based entity street
address
Web-based entity city
Web-based entity state
Web-based entity zip
code
Web-based entity
phone
Web-based entity email
address
Web-based entity URL*
Web-based entity
National Producer
Number*
Web-based entity
National Producer
Number confirmation*
Web-based entity
state(s) of licensure*


File Typeapplication/pdf
AuthorDaniel S Brown
File Modified2015-07-02
File Created2015-07-02

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