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*

Employer Group Name*

Billing Contact Name*

Billing Contact Phone*

Phone

Billing Contact Email*

Email Address

Enrollment Platform Type*

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

Is Eligibility Ongoing 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 does one complimentary data audit annually to the medical plan only. We encourage the employer to monitor their bill on a monthly basis

Yes, ongoing support is needed

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

Data Auditing*

It is highly recommended that clients have an audit/reconciliation process in place to audit and reconcile carrier invoices and enrollment data monthly. If no solution is in place, BBS will schedule a demonstration of the Data Validation Platform with the client to illustrate how the client may use our Data Validation Platform as a Self-Service audit solution. Should the client choose to subscribe to the platform, the cost associated with the subscription of the platform is the responsibility of the client unless otherwise indicated. Do you have an auditing solution in place?

Yes

No

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

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

Does your current solution include any of the following?*

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

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

OPT IN: I am considering the Data Validation Platform subscription 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.

Terms & Service Level Agreement

Terms and Conditions*

By checking this box, I agree that during the term of this Agreement, I, the client shall pay Broker Builder Solutions, LLC for its Services under this Agreement based on the fee structure that corresponds with my service model (a la carte vs. Agency Support) and the file type being selected. 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 further agree that BBS will invoice me on the 1st of the month for all files, integration, and ongoing support requested above.

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 Terms & Service Level Agreement*

By checking this Box, I acknowledge and verify that I have read and agree to the Terms and 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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