Form Py2018 - Qhp Application Data Change Request - Department Of Health
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1
2
3DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
QHP Application Data Change Request Form PY2018
This document includes fillable form fields. If you complete electronically, please: a) Type
directly in the fields below (all fields are required); b) Click on the signature field to sign
electronically; c) Save the file to your desktop; d) Email the form as an attachment to
CMS_FEPS@cms.hhs.gov.
If you write in your responses, please a) Complete the fields below (all fields are required); b)
Print the form; c) Sign the form; and d) Scan the form and email to
CMS_FEPS@cms.hhs.gov.
This attachment provides information to the Centers for Medicare & Medicaid Services regarding
QHP or SADP data changes requested by:
Issuer ID:
_____________________________________
State:
_____________________________________
Issuer Legal Name: _____________________________________
Impacted Plan IDs:
_________________________________________________________________________________
_________________________________________________________________________________
Impacted QHP Templates and Field (if possible provide column or field reference) (Check 1):
Accreditation (NCQA or URAC): _____________________________________________
Issuer Module - Program Attestation, Licensure, Good Standing, or Network
Adequacy/Essential Community Providers
Issuer Module Supporting Documents- Organization Chart, Compliance Plan, Licensure/Good
Standing documents, ECP/NA justifications, QIS
Network Adequacy/Essential Community Providers (template): ________________________
Plan and Benefits Template*
Individual
SHOP
Dental Individual
Dental SHOP
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Does this affect your Actuarial Value (AV) calculation?
Yes (if yes, the issuer needs to submit the plan’s old and new AV Calculator
screenshots, along with a copy of the old and new version of the Plans and Benefits
Template)
No
Network ID: ________________________________________________________________
Service Area*: _______________________________________________________________
Updated 3/30/17
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