Federally-Facilitated Marketplace (Ffm) User Fee Adjustment Web Form Quick Startguide - Centers For Medicare And Medicaid Services Page 14

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FFM User Fee Adjustment Web Form Quick Start Guide
4.2.1
Summary Page – TPA/PBM
Table 6: Summary Page – TPA/PBM
Step
Action
1
Review the TPA/PBM Notice of Intent section to confirm the following:
•
Correct name of TPA or PBM was entered
•
Correct Self-Certification date was entered
•
Correct TPA/PBM mailing address was entered
•
Correct answer is selected for the question, “Do you intend to arrange
for a participating issuer to seek a Federally-facilitated Marketplace User
Fee Adjustment on your behalf?”
Select the Edit link next to the TPA/PBM Notice of Intent section to edit any
details.
2
Review the TPA/PBM Report of Contraceptive Claims Costs section to
confirm the following:
•
Correct TPA or PBM name was entered
•
Correct TPA or PBM Tax Identification Number was entered
•
Correct Number of participants and beneficiaries in each self-insured
plan was entered
•
Correct dollar amount of payments for contraceptive services for plan
participants and beneficiaries paid by a TPA/PBM was entered
Select the Action link (View or Edit) next to the TPA or PBM name you would
like to view or edit.
3
Review the Contact Information section on the Summary page for accuracy.
Select the Edit Contact Information button to edit contact information.
4
Select the Continue button.
You will be directed to the appropriate Attestation page of the web form.
FFM User Fee Adjustment Web Form Quick Start Guide
14

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