EDI Carrier Contact

EDI Carrier Contact & Case Setup Form

PLEASE NOTE: THIS FORM WILL AUTOSAVE YOUR ANSWERS AS LONG AS YOU ARE USING THE SAME BROWSER WHEN YOU RETURN TO THE FORM

Information needed for purpose of developing carrier feeds.

Please use the “ADD NEW CARRIER” Button to repeat the Section to add more Carriers.

Services

EDI 834 File: Typically medical, dental, vision plans Includes up to 25 Rules to map within the Account Structure. 26-100 Rules incur additional charges **

Data Exchange Implementation: Typically, voluntary and cafeteria plans, COBRA, and a few medical plans such as UHC or Sierra Health, BCBS-SC, etc.

Proprietary File or Payroll File: Carriers or providers that are not integrated or pre-configured with your Ben Admin portal.

Agency Name*

Agency Point of Contact*

Agency Point of Contact - Email*

Billing Contact Name*

Who is the Billing Party?*

Agency

Employer Group / Client Direct

Carrier

Acknowledgement : If the billing party is not the referring agency, BBS requires that a valid credit card be placed on file at the time-of-service request. Our Finance team will contact the billing contact directly to securely collect this information. The card will only be charged in the event that payment is not received within 90 days of the invoice date.*

Yes, I understand

Billing Contact Phone*

Phone

Billing Contact Email*

Email Address

Employer Group Name*

Enrollment Platform Type*

If "Other" selected above, please enter platform type:

Is Ongoing Eligibility Maintenance Support needed?*

Additional Cost Will Apply

Check “Yes” for Ongoing EDI Support if the expectation is for BBS to provide monthly support for the client’s EDI files. Please note that a monthly cost will apply. Below is a description of what Ongoing Support entails:

Manage the ongoing eligibility maintenance of file year-round and monitor the weekly file transmission to ensure the file is transmitted to the carrier timely
Troubleshoot and resolve file transmission protocol issues
Receive and work the weekly error reports
Manage the carrier expectations at Open Enrollment
Update the file configuration for Renewal
BBS completes one complimentary data audit before placing the file into production. It is industry best-practice for the bill to be reviewed monthly and enrollment data to be audited quarterly.

Yes, ongoing support is needed

No, I can manage weekly file reports and transmission errors on my own

Please provide Name and Email of person who should receive any Error Reports after the file has moved into production:*

Name of Contact Person

Email*

Email of Contact Person

BBS defaults the file to send weekly on Wednesdays. Please choose an option below if you would like to receive the file on a different day:*

Monday

Tuesday

Thursday

Friday

No change - default day of Wednesday is fine.

Data Auditing*

It is highly recommended that clients have an audit/reconciliation process in place to audit and reconcile carrier invoices monthly and enrollment data quarterly. Broker Builder Solutions, in partnership with our affiliate company, Data Management Solutions, offers a monthly Audit on Demand Service to audit/reconcile data based on industry best practices. Do you have an auditing solution in place?

Yes

No

SELECT ONE OPTION BELOW (Opt-In or Decline by Opting Out of the DVP subscription):*

OPT IN: Please add the Monthly Invoice Reconcillation Service for $40/month

OPT IN: Please add the Monthly Invoice Reconciliation & Quarterly Enrollment Census Audit Service for $55/month

OPT IN: I am considering the self-service Data Validation Platform as an option and would like to be contacted to schedule a demo and learn more about the subscription process.

OPT OUT: My agency/employer group has an alternate method for monthly reconciliation audits.

How frequently does your organization audit/ reconcile enrollment data?*

Does your current solution include any of the following?*

If "Other" selected above, please provide a brief description:

Terms & Service Level Agreement

Terms and Conditions*

By checking this box, I agree that the term of the ongoing support agreement and any add on audit services shall begin on the date this form is signed (the effective date) and shall continue in full force and effect for a term of one (1) year, provided that the Term shall automatically renew for successive one-year periods unless either Broker Builder Solutions, LLC/ Data Management Solutions- Data Validation Platform, LLC or the client sends written notice to the other of its intent to terminate this agreement at least 60 days before the day the Term would otherwise expire.

I further agree that during the term of this Agreement, I , the client shall pay Broker Builder Solutions, LLC/ Data Management Solutions- Data Validation Platform, LLC for its Services under this Agreement based on the fee structure that corresponds with my service model (a la carte vs. Agency Support), the file type being selected, and the contract terms as outlined in my Master Ongoing Support Service agreement. I understand that these fees include mapping for up to 25 rules and I am subject to additional fees for mapping rules beyond 25 rules (26-100).

Requests for additional services should be completed via Broker Builder Solutions LLC, company website: brokerbuildersolutions.com > Forms > Applicable Checklist or, Contact Us > Request for Quote. All requests made on the site act as an extension of this agreement. Costs may be subject to change as BBS deems necessary. BBS will inform the current client if a cost change occurs.

I understand that I will be invoiced on the 1st of the month for all files, integration, ongoing support, and audit services requested above and that invoices are due upon receipt.

If the billing party is not the referring agency, BBS requires that a valid credit card be placed on file at the time-of-service request. Our Finance team will contact the billing contact directly to securely collect this information. The card will only be charged in the event that payment is not received within 90 days of the invoice date.

Terms of Service: Our Data Management Solutions products and services adhere to the Broker Builder Solutions Terms of Service. These terms may be accessed by clicking here.

Yes, I agree

Acknowledgement of EDI Service Level Agreement*

By checking this Box, I acknowledge and verify that I have read and agree to the EDI Service Level Agreement Document located here.

Signature for Terms and Conditions*

Your Full Name

Your Title

Signature

Date*

Select Date ×

EDI Carrier Contact

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