Form Py2018 - Qhp Application Data Change Request - Department Of Health Page 2
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3Prescription Drug: ____________________________________________________________
Benefits and Service Area Module - Supporting Documentation
Rates Table: ________________________________________________________________
Does this affect your Unified Rate Review Template (medical QHPs only)?
Yes
No
Business Rules*:______________________________________________________________
Description of requested QHP or SADP data changes:
If additional space is needed, please include an attachment to your request
Templates marked with a * require Supplement B in addition to this worksheet
Current Value:
___________________________________________________
Requested New Value:
___________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Reason for Requested QHP or SADP Data Changes:
Issuer submitted incorrect data on QHP/SADP template(s) and must make a change to align
template(s) with QHP/SADP data previously approved by the applicable state (or CMS Form
Filing if in a Direct Enforcement state). Evidence from the form filing section must be
attached.
Issuer submitted a typographical (i.e., data entry) error for which the first justification does
not apply, resulting in incorrect data display on the Marketplace consumer portal. Evidence
must be attached.
Issuer is making routine updates to the administrative information, which includes URL
changes.
Additional detail to justify need for changes:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
State Approval Documentation
State evidence of approval is included (required for Federally-Facilitated Marketplace (FFM)
states, AND/OR
Request is for a medical or dual issuer in a Direct Enforcement state and CMS Form Filing
approval is included; OR
Request is for an issuer in a state performing plan management functions
Updated 3/30/17
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