Form CMS-10433 Administrative Data Template

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