CMS-10433 QHP Certification Instrument Screenshots

OMB control number 0938-1187
Expiration Date: xx/xx/xxxx
Centers for Medicare & Medicaid Services (CMS) Qualified Health Plan (QHP) Transparency in Coverage Reporting
Plan Year 2019
Please complete the fields below, following the instructions in the Transparency in Coverage QHP Issuer Instruction Guide.
General Information
Was this plan on the Exchange in 2017?
Issuer Name
Issuer D/B/A, if Applicable
Issuer HIOS ID
Issuer Point of Contact Name
Issuer Point of Contact E-mail Address
Issuer Point of Contact Phone Number
Issuer Backup Point of Contact
Issuer Backup Point of Contact E-mail Address
Issuer Backup Point of Contact Phone Number
2019 Data: Reporting of all fields is required for 2019
Claims Payment Policies & Other Information URL
Number of Claims Received in Calendar Year 2017 for Services Rendered in 2017
Number of Claims Denied in Calendar Year 2017
Number of Internal Appeals Filed in Calendar Year 2017
Number of Internal Appeals Overturned from Calendar Year 2017 Appeals
Number of External Appeals Filed in Calendar Year 2017
Number of External Appeals Overturned from Calendar Year 2017 Appeals
Notes: (Please enter any comments/notes here.)

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PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1187, expiration date is xx/xx/xxxx. The time required to complete this information collection is estimated to take up to 282.25 hours per issuer per year, including the time to
review instructions, gather the information needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.