Form CMS-10433 Reinsurance and Risk Adjustment Bank Server

Appendix M – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
CMS will collect data required from issuers, group health plans, and third party administrators on
behalf of either for the Transitional Reinsurance, permanent Risk Adjustment and Risk Corridors
programs established by the Affordable Care Act of 2010. In addition, CMS will collect banking
information to remit payments to applicable entities.
To ensure accurate information, consistent presentation, and minimize the burden on applicants,
extensive analysis has been conducted to determine the minimum data necessary for
administering the Transitional Reinsurance program, Risk Adjustment program, Risk Corridors
program and payment operations.
Administrative Data Elements (as applicable)
The section requests that issuers, self-insured and third party administrators when providing
services on behalf of either provide basic information required to identify them to facilitate
communications and necessary program operations. Data will be pre-populated from HIOS or
other templates whenever possible.
Issuer, Self-Insured and TPA Data
1. HIOS Issuer ID
2. HIOS Company ID
3. Associated HPID
4. Associated OEID
5. State
6. Proposed Exchange Market Coverage
7. Current Sales Market
8. Company Legal Name
9. TIN
10. Not-for-Profit
11. NAIC Company Code
12. NAIC Group Code
13. Name of Holding Company
14. Legal Name
15. Marketing Name
16. Company Address: Address
17. Company Address: Address 2
18. Company Address: City
19. Company Address: State
20. Company Address: Zip Code
21. Issuer: Address
22. Issuer: Address 2
23. Issuer: City
24. Issuer: State
25. Issuer: Zip Code
Contacts
26. Main Company Contact: First Name
27. Main Company Contact: Last Name
28. Main Contact: E-mail
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Appendix M – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
29. Main Company Contact: Phone Number
30. Main Company Contact: Phone Ext
31. CEO: First Name
32. CEO: Last Name
33. CEO: E-mail
34. CEO: Phone Number
35. CEO: Phone Ext
36. CFO: First Name
37. CFO: Last Name
38. CFO: E-mail
39. CFO: Phone Number
40. CFO: Phone Number Ext
41. Compliance Officer: First Name
42. Compliance Officer: Last Name
43. Compliance Officer: E-mail
44. Compliance Officer: Phone Number
45. Compliance Officer: Phone Number Ext
46. Compliance Officer: E-mail
47. Enrollment Contact: First Name
48. Enrollment Contact: Last Name
49. Enrollment Contact: Phone Number
50. Enrollment Contact: Phone Number Ext
51. Enrollment Contact: E-mail
52. System Contact: First Name
53. System Contact: Last Name
54. System Contact: Phone Number
55. System Contact: Phone Number Ext
56. System Contact: E-mail
57. Payment Contact: First Name
58. Payment Contact: Last Name
59. Payment Contact: Phone Number
60. Payment Contact: Phone Number Ext
61. Payment Contact: E-mail
62. HIPAA Security Officer: First Name
63. HIPAA Security Officer: Last Name
64. HIPAA Security Officer: Phone Number
65. HIPAA Security Officer: Phone Number Ext
66. HIPAA Security Officer: E-mail
67. Complaints Tracking Contact: First Name
68. Primary Contact: Individual or Small Group
69. Individual Market Contact: First Name
70. Individual Market Contact: Last Name
71. Individual Market Contact: Phone Number
72. Individual Market Contact: Phone Number Ext
73. Individual Market Contact: E-mail
74. SHOP Contact: First Name
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Appendix M – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
75. SHOP Contact: Last Name
76. SHOP Contact: Phone Number
77. SHOP Contact: Phone Number Ext
78. SHOP Contact: E-mail
79. APTC/CSR Contact: First Name
80. APTC/CSR Contact: Last Name
81. APTC/CSR Contact: Phone Number
82. APTC/CSR Contact: Phone Number Ext
83. APTC/CSR Contact: Email
84. Risk Corridors Contact: First Name
85. Risk Corridors Contact: Last Name
86. Risk Corridors Contact: Phone Number
87. Risk Corridors Contact: Phone Number Ext
88. Risk Corridors Contact: Email
89. Risk Adjustment Contact: First Name
90. Risk Adjustment Contact: Last Name
91. Risk Adjustment Contact: Phone Number
92. Risk Adjustment Contact: Phone Number Ext
93. Risk Adjustment Contact: Email
94. Reinsurance Contact: First Name
95. Reinsurance Contact: Last Name
96. Reinsurance Contact: Phone Number
97. Reinsurance Contact: Phone Number Ext
98. Reinsurance Contact: Email
99. Financial Transfers Contact: First Name
100. Financial Transfers Contact: Last Name
101. Financial Transfers Contact: Phone Number
102. Financial Transfers Contact: Phone Number Ext
103. Financial Transfers Contact: E-mail
104. Third Party Administrator (TPA) ID
105. Third Party Administrator (TPA) Name
106. Third Party Administrator (TPA) Process
107. Third Party Administrator (TPA) Process URL/EDI Gateway Info
108. Third Party Administrator (TPA) Confirmation of Services
Miscellaneous
109. Do you have a TPA that currently provides services for the following processes:
Marketplace Enrollment (Y/N), Claims Processing (Y/N), Edge Server (Y/N)
110. Will you allow employees to “buy up” to a higher metal-level coverage than their
employer is offering?
State Licensure and Good Standing Documentation
State licensure documentation necessary to demonstrate that an issuer is licensed and has
authority to sell all applicable products in the services areas in which it intends to offer those
products. If license and certificate of authority are not in possession for all service areas,
attestation that license and certificate of authority will be obtained and a projected date of
obtaining license.
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Appendix M – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
Good standing documentation necessary to demonstrate that an issuer is in compliance with all
applicable State solvency requirements and other relevant State regulatory requirements.
Attestations (as applicable)
1. Applicant attests that it will adhere to the risk corridor standards and requirements set by
HHS as applicable for:
a) risk corridor data standards and annual HHS notice of benefit and payment.
parameters for the calendar years 2014, 2015, and 2016 (45 CFR 153.510); and
b) remit charges to HHS under the circumstances described in 45 CFR 153.510(c).
2. The following applies to applicants participating in the risk adjustment and reinsurance
programs inside and/or outside of the Exchange (Marketplace). Applicant attests that it
will:
a) adhere to the risk adjustment standards and requirements set by HHS in the annual
HHS notice of benefit and payment parameters (45 CFR Subparts G and H);
b) remit charges to HHS under the circumstances described in 45 CFR 153.610;
c) adhere to the reinsurance standards and requirements set by HHS in the annual HHS
notice of benefit and payment parameters (45 CFR 153.400, 153.405, 153.410,
153.420);
d) remit contributions to HHS under the circumstances described in 45 CFR 153.405;
e) establish dedicated and secure server environments to host enrollee claims, encounter,
and enrollment information for the purpose of performing risk adjustment and
reinsurance operations for all plans offered;
f) allow proper interface between the dedicated server environment and special,
dedicated CMS resources that execute the risk adjustment and reinsurance operations;
g) ensure the transfer of timely, routine, and uniform data from local systems to the
dedicated server environment using CMS-defined standards, including file formats
and processing schedules;
h) comply with all information collection and reporting requirements approved through
the Paperwork Reduction Act of 1995 and having a valid OMB control number for
approved collections. The Issuer will submit all required information in a CMSestablished manner and common data format;
i) cooperate with CMS, or its designee, through a process for establishing the server
environment to implement these functions, including systems testing and operational
readiness;
j) use sufficient security procedures to ensure that all data available electronically are
authorized and protect all data from improper access, and ensure that the operations
environment is restricted to only authorized users;
k) provide access to all original source documents and medical records related to the
eligible organization’s submissions, including the beneficiary's authorization and
signature to CMS or CMS’ designee, if requested, for audit;
l) retain all original source documentation and medical records pertaining to any such
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Appendix M – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
particular claims data for a period of at least 10 years;

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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
m) be responsible for all data submitted to CMS by itself, its employees, or its agents and
based on best knowledge, information, and belief, submit data that are accurate,
complete, and truthful;
n) all information, in any form whatsoever, exchanged for risk adjustment shall be
employed solely for the purposes of operating the premium stabilization programs
and financial programs associated with state markets, including but not limited to, the
calculation of user fees to fund such programs, oversight, and any validation and
analysis that CMS determines necessary;
3. Under the False Claims Act, 31 U.S.C. §§ 3729-3733, those who knowingly submit, or
cause another person or entity to submit, false claims for payment of government funds
are liable for three times the government’s damages plus civil penalties of $5,500 to
$11,000 per false claim. 18 U.S.C. 1001 authorizes criminal penalties against an
individual who in any matter within the jurisdiction of any department or agency of the
United States knowingly and willfully falsifies, conceals, or covers up by any trick,
scheme, or device, a material fact, or makes any false, fictitious or fraudulent statements
or representations, or makes any false writing or document knowing the same to contain
any false, fictitious or fraudulent statement or entry. Individual offenders are subject to
fines of up to $250,000 and imprisonment for up to 5 years. Offenders that are
organizations are subject to fines up to $500,000. 18 U.S.C. 3571(d) also authorizes fines
of up to twice the gross gain derived by the offender if it is greater than the amount
specifically authorized by the sentencing statute. Applicant acknowledges the False
Claims Act, 31 U.S.C. §§ 3729-3733.
4. Applicant attests to provide and promptly update when applicable changes occur in its
Tax Identification Number (TIN) and associated legal entity name as registered with the
Internal Revenue Service, financial institution account information, and any other
information needed by CMS in order for the applicant to receive invoices, demand letters,
and payments under the reinsurance, risk adjustment, and risk corridor programs, as well
as, any reconciliations of the aforementioned programs.
5. Applicant attests that it will develop, operate and maintain viable systems, processes,
procedures and communication protocols to accept payment-related information
submitted by CMS.
Plan Data Elements (as applicable)
The following is a list of the specific plan-level identification information to be provided for
non-Exchange plans in the individual and small group market.
1. Plan ID
2. Plan Marketing Name
3. HIOS Product ID
4. Market Type
5. Exchange QHP? (Y/N)
• If off-Exchange, is it the same or substantially the same as a certified Exchange QHP?
Same, Substantially the same, No
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
• If the same or substantially the same as a certified Exchange QHP, provide HIOS Plan
ID (14-digit standard component) for the certified Exchange QHP.
6. Level of Coverage
7. Issuer calculated actuarial value?
8. Metal Level
9. Child–Only Offering
10. Child–Only Plan ID
11. Plan Type
12. New or Existing Plan Indicator
13. Plan Effective Date
14. Plan Expiration Date
15. Maximum Out–of–Pocket Individual In–Network for EHBs (combined amount for
medical and drug)
16. Maximum Out–of–Pocket Family In–Network for EHBs (combined amount for medical
and drug)
17. Federal Tax ID
18. Associated HPID
19. Non-grandfathered (Y/N)
20. Type of Plan Offering: Student Health Plan (Y/N), Medicaid (Y/N), Basic Health Plan
(Y/N), Excepted Benefit Plan-Not Standalone Dental (Y/N), Short Term Limited
Duration Plan (Y/N), Other (Y/N)
Rating Tables and Issuer Business Rules (as applicable)
The following is a list of the specific rating table and issuer business rules data elements to be
collected for non-Exchange plans in the individual and small group market.
1. Issuer ID
2. Federal TIN
3. Plan ID
4. Rating Area ID
5. Product Level Rules
6. Plan Level Rules (14-digit number that identifies the plan)
7. Are you in a community rated state? (Y/N) If yes, are your premiums based on family
tiering? (Y/N)
8. What is the maximum number of underage (under 21) dependents used to quote rates for
a two-parent family? In which order are children rated, oldest to youngest or youngest to
oldest?
9. What is the maximum number of underage (under 21) dependents used to quote rates for
a single parent family? In which order are children rated, oldest to youngest or youngest
to oldest?
Banking Data (as applicable)
The following is a list of the specific banking data to be collected from all entities eligible to
receive payments.
1. Reason for Submission: New EFT Authorization (Y/N), Revision to Current
Authorization (e.g. account or financial institution changes) (Y/N)

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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
2. Check here if EFT payment is being made to the Affiliate of the Entity
(Attach letter authorizing EFT payments to the Affiliated Entity)
3. Since your last EFT authorization agreement submission, have you had a
Change of Ownership and/or Change of Address? (Y/N) If yes, submit a
change of information prior to accompanying this EFT authorization.
4. Entity ID
5. Vendor ID
6. HIOS ID
7. HPID ID
8. Entity name (Legal) – Legal entity name should be the same name provided to
the Internal Revenue Service on Form W-9, Request for Taxpayer
Identification Number (TIN) and Certification
9. Entity: Name (DBA)
10. Entity: Name (Division)
11. Entity: Address
12. Entity: Address 2 – Address should include routing information (e.g.
Attention: Accounting Department)
13. Entity: City
14. Entity: State
15. Entity: Zip Code
16. Entity: Country
17. Entity: TIN
18. List of all Entity Affiliated HIOS IDs
19. List of all Entity Affiliated HIOS ID Names
20. List of all Entity Affiliated HPID IDs
21. IRS 1099: Address
22. IRS 1099: Address 2
23. IRS 1099: City
24. IRS 1099: State
25. IRS 1099: Zip Code
26. IRS 1099: Country
27. Copy of Voided Check
28. Letter from Financial Institution for Account Validation
29. Financial Institution Routing Transit Number
30. Entity Depositor Account Number
31. Type of Account: Checking or Savings
32. Plastic Card Holder Name
33. Plastic Card Holder Billing Address
34. Plastic Card Holder Billing City
35. Plastic Card Holder Billing State
36. Plastic Card Holder Billing Zip Code
37. Plastic Card Holder Country
38. Plastic Card Type: Credit Card or Debit Card
39. Plastic Card Company: Visa, Master Card, American Express, or Discover
40. Plastic Card Holder Number
41. Plastic Card Holder Expiration Date
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
42. Plastic Card Holder Security Code
43. Payment Amount
44. Invoice Number
45. Invoice Date
46. Check Payment Remittance Contact: Title (up to four instances)
47. Check Payment Remittance Contact: First Name (up to four instances)
48. Check Payment Remittance Contact: Last Name (up to four instances)
49. Check Payment Remittance Contact: Phone Number (up to four instances)
50. Check Payment Remittance Contact: Phone Number Ext (up to four instances)
51. Check Payment Remittance Contact: E-mail (up to four instances)
52. Check Payment Remittance Contact: Address (up to four instances)
53. Check Payment Remittance Contact: Address 2 (up to four instances)
54. Check Payment Remittance Contact: City (up to four instances)
55. Check Payment Remittance Contact: State (up to four instances)
56. Check Payment Remittance Contact: Zip Code (up to four instances)
57. Check Payment Remittance Contact: Country (up to four instances)
58. EFT Banking Information: Title (up to four instances)
59. EFT Banking Information: First Name (up to four instances)
60. EFT Banking Information: Last Name (up to four instances)
61. EFT Banking Information: Phone Number (up to four instances)
62. EFT Banking Information: Phone Number Ext (up to four instances)
63. EFT Banking Information: E-mail (up to four instances)
64. EFT Banking Information: Bank Name (up to four instances)
65. EFT Banking Information: Address (up to four instances)
66. EFT Banking Information: Address 2 (up to four instances)
67. EFT Banking Information: City (up to four instances)
68. EFT Banking Information: State (up to four instances)
69. EFT Banking Information: Zip Code (up to four instances)
70. EFT Banking Information: Country (up to four instances)
71. Profit/Non-Profit Indicator
72. Change of Ownership Date
73. Business Line to which this banking information is applicable – Also referred
to as “Business Line” or “Program Type;” includes FFM User Fees, Advanced
Premium Tax Credits (APTC), Cost Sharing Reductions (CSR), Reinsurance,
Risk Corridors, and Risk Adjustment programs.
74. Financial Reporting IP Address
75. Authorized/Delegated Official: Title
76. Authorized/Delegated Official: First Name
77. Authorized/Delegated Official: Last Name
78. Authorized/Delegated Official: Phone Number
79. Authorized/Delegated Official: Phone Number Ext
80. Authorized/Delegated Official: E-mail
81. Authorized/Delegated Official: Signature
82. Date of Authorization
83. Payment Contact: First Name
84. Payment Contact: Last Name
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
85. Payment Contact: Phone Number
86. Payment Contact: Phone Number Ext
87. Payment Contact: E-mail
88. Financial Transfers Contact: First Name
89. Financial Transfers Contact: Last Name
90. Financial Transfers Contact: Phone Number
91. Financial Transfers Contact: Phone Number Ext
92. Financial Transfers Contact: E-mail
93. Electronic Funds Transfer Authorization Agreement: I hereby authorize the
Centers for Medicare & Medicaid Services (CMS) to initiate credit entries,
and in accordance with 31 CFR part 210.6(f) initiate adjustments for any
duplicate or erroneous entries made in error to the account indicated above. I
hereby authorize the financial institution/bank named above to credit and/or
debit the same to such account. CMS may assign its rights and obligations
under this agreement to CMS’ designated contractor. CMS may change its
designated contractor at CMS’ discretion. If payment is being made to an
account controlled by an Affiliated Entity, referred to as Payee Group, the
Entity, also known as Health Insurance Company, hereby acknowledges that
payment to the Payee Group under these circumstances is still considered
payment to the Health Insurance Company, and the Health Insurance
Company authorizes the forwarding of payments to the Payee Group. If the
account is drawn in the Health Insurance Company’s name, or the Legal
Business Name of the Health Insurance Company, the said Health Insurance
Company certifies that he/she has sole control of the account referenced
above, and certifies that all arrangements between the Financial Institution
and the said Health Insurance Company are in accordance with all applicable
CMS regulations and instructions. This authorization agreement is effective
as of the signature date below and is to remain in full force and effect until
CMS has received written notification from me of its termination in such
time and such manner as to afford CMS and the Financial Institution a
reasonable opportunity to act on it. CMS will continue to send the direct
deposit to the Financial Institution indicated above until notified by me that I
wish to change the Financial Institution receiving the direct deposit. If my
Financial Institution information changes, I agree to submit to CMS an
updated signed EFT Authorization Agreement.
94. Are you an insurance company?
95. Effective Date for Financial Information
96. Financial Authority Contact: Title
97. Financial Authority Contact: First Name
98. Financial Authority Contact: Last Name
99. Financial Authority Contact: Phone Number
100. Financial Authority Contact: E-mail
101. Financial Institution: Name
102. Financial Institution: City
103. Financial Institution: State
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
104. Financial Institution: Zip
105. Financial Institution Contact: First Name
106. Financial Institution Contact: Last Name
107. Financial Institution Contact: Phone Number
108. Financial Institution Contact: Phone Number Ext
109. Financial Information Form Contact: First Name
110. Financial Information Form Contact: Last Name
111. Financial Information Form Contact: Title
112. Financial Information Form Contact: Phone Number
113. Financial Information Form Contact: Phone Number Ext
114. Financial Information Form Contact: Email
115. Payee Group: TIN
116. Payee Group: HPID ID
117. Payee Group Contact: Title
118. Payee Group Contact: First Name
119. Payee Group Contact: Last Name
120. Payee Group Contact: Phone Number
121. Payee Group Contact: Phone Number Ext
122. Payee Group Contact: Email
123. Payee Group Contact: Address
124. Payee Group Billing Address: Address
125. Payee Group Billing Address: Attention
126. Payee Group Billing Address: City
127. Payee Group Billing Address: State
128. Payee Group Billing Address: Zip Code
129. Is the payee group an Organization Level Payee?
130. Legal Business Name with no special characters except ampersands and hyphens
131. Type of Corporate Entity
132. Copy of W-9
EDGE Server Registration and Provisioning Data
The following is a list of the specific data required for the Edge Server registration and
provisioning process.
AWS EDGE Server Registration Data Elements
SECTION 1: ISSUER CONTACTS (primary and secondary are required)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
12. Secondary Contact: email address
13. Secondary Contact: Phone Number
14. Secondary Contact: Phone Number Ext

SECTION 2: ISSUER SUPPLEMENTAL CONTACTS (maximum of 2; optional)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

SECTION 3: ISSUER AWS EDGE SERVER INFORMATION - SELF HOSTED
1. Name of EDGE Server (provided by the Issuer)
2. Insurance Company - Legal name of the insurance company responsible for the EDGE Server
3. Issuer Name - Legal name of the issuer responsible for the EDGE Server
4. HIOS Issuer ID
5. EDGE Server Size - small, medium, or large
6. Amazon Web Services (AWS) Region - US East, US West - Oregon, US West – N. California
7. AWS Account Information – includes AWS account number for the registering organization and
AWS Key Pair Name (AWS key name associated with the AWS account that is used to provision
the EDGE server)

SECTION 4: THIRD PARTY ADMINISTRATOR AWS EDGE SERVER
INFORMATION - TPA HOSTED
1. Name of EDGE Server
2. TPA Company - Legal name of the TPA company hosting the EDGE Server 3. Issuer Name Legal name of the issuer responsible for the EDGE Server
4. TPA Identifier – (issuer selects from a list)
5. EDGE Server Size - small, medium, or large
6. Amazon Web Services (AWS) Region - US East, US West - Oregon, US West – N. California
7. AWS Account Information – includes AWS account number for the registering organization and
AWS Key Pair Name (AWS key name associated with the AWS account that is used to provision
the EDGE server)

SECTION 5: TPA CONTACTS (primary and secondary required) - TPA HOSTED
1.
2.
3.
4.
5.
6.
7.
8.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
9.
10.
11.
12.
13.
14.

Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 6: TPA SUPPLEMENTAL CONTACTS (maximum of 2; optional) - TPA
HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

Issuer On-Premise EDGE Server Registration Data Elements
SECTION 1: ISSUER CONTACTS (primary and secondary are required)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 2: ISSUER SUPPLEMENTAL CONTACTS (maximum of 2; optional)
1.
2.
3.
4.
5.
6.
7.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
8.
9.
10.
11.
12.
13.
14.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext

SECTION 3: ISSUER EDGE SERVER INFORMATION - ON PREMISE SELF
HOSTED
1. Name of EDGE Server (provided by the Issuer)
2. Insurance Company - Legal name of the insurance company responsible for the EDGE Server 3.
Issuer Name - Legal name of the issuer responsible for the EDGE Server 4. HIOS Issuer ID 5.
EDGE Server Size - small, medium, or large

SECTION 4: THIRD PARTY ADMINISTRATOR EDGE SERVER INFORMATION
ON-PREMISE - TPA HOSTED
1. Name of EDGE Server
2. TPA Company - Legal name of the TPA company hosting the EDGE Server 3. Issuer Name Legal name of the issuer responsible for the EDGE Server
4. TPA Identifier - (issuer selects TPA from list)
5. EDGE Server Size - small, medium, or large

SECTION 5: TPA CONTACTS (primary and secondary required) - TPA HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Primary Contact: Prefix (optional)
Primary Contact: First Name
Primary Contact: Last Name
Primary Contact: Job Title (optional)
Primary Contact: email address
Primary Contact: Phone Number
Primary Contact: Phone Number Ext
Secondary Contact: Prefix (optional)
Secondary Contact: First Name
Secondary Contact: Last Name
Secondary Contact: Job Title (optional)
Secondary Contact: email address
Secondary Contact: Phone Number
Secondary Contact: Phone Number Ext

SECTION 6: TPA SUPPLEMENTAL CONTACTS (maximum of 2; optional) - TPA
HOSTED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
Supplemental Contact: email address
Supplemental Contact: Phone Number
Supplemental Contact: Phone Number Ext
Supplemental Contact: Prefix (optional)
Supplemental Contact: First Name
Supplemental Contact: Last Name
Supplemental Contact: Job Title (optional)
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Appendix D – Transitional Reinsurance Program, Risk Adjustment Program, and
Payment Operations Data Requirements
12. Supplemental Contact: email address
13. Supplemental Contact: Phone Number
14. Supplemental Contact: Phone Number

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