Self-Funded Large Group Market

Data Needed if currently Self-Funded (Large Group Market)

• Employee Census REQUIRED, and to include (must have these elements):
  • Gender (M/F)
  • Date of Birth (MM/DD/YYYY)
  • Zip Code (5 digit)
  • State (XX)
  • Tier Election (EE Only, EE+Spouse, EE+Child(ren), Family, Waived, Waiting Period, Not Eligible, Refusing Coverage)
  • COBRA Indicator (Y/N)
  • Plan Election (if more than one plan must be included)
  • Retiree Indicator (Y/N)

• Current Year + Renewal Year Rates:  Admin, if available & Stop Loss (Stop Loss – include copy of Stop Loss policy, if available)
• Current and Renewal Year Plan Design Details, please send in Schedule of Benefits and note any requested future plan changes
• Claims data to include:
  • 24 months of Monthly Medical & Rx Paid Claim Data, run by Plan Year dates, Aggregate Reporting is acceptable
  • Monthly Enrollment Data (should cover same time period(s) as monthly claim data)
  • Rx Repricing:  Minimum of 12 months, up to 24 months, Rx claim detail reporting, please include a listing of Rx Rebates received for the same period
    • Large claims data including any member with claims paid @ 50% of requested Spec level, include total paid claims, diagnosis, and prognosis (if available) (should cover same time period(s) as monthly claim data)

Enter the information above into the form below and send your data contents as specified by group size to CAM@varipro.com