CMS-10433 NCQA Template

NCQA Template
All fields with an asterisk (*) are required. To validate the template, use the Validate button or Ctrl + Shift + V. To finalize the template, use the Finalize button or Ctrl + Shift + F.
The information for the accredited products must be for the same legal entity as is submitting the QHP application.
Please follow the instructions provided in the Accreditation Chapter (Chapter 5) of the QHP Application Instructions Manual closely and carefully.
The Department of Health and Human Services (HHS) will verify the information that you have provided about your existing accreditation with NCQA, URAC, or both.
Only data that can be verified will be displayed on the website.
It is only necessary to enter one accreditation entry per product/market type, using the product with the largest number of covered lives.
HIOS Issuer ID*
NCQA Org ID* Required: Enter the 2-5-digit NCQA Org ID number	Market Type* Required: Select the Market Type from list	NCQA Sub ID Required if Market is NOT Exchange: Enter the 2-5-digit NCQA Sub ID number	Product Type* Required: Select the Product Type from list	Product ID* Required: Enter the 10-character Product ID	Accreditation Status* Required: Select the Accreditation Status from list	Expiration Date* Required: Enter a future date in mm/dd/yyyy format