Client Name
Business
Address
State
City Alabama Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington, D.C. Washington State West Virginia Wisconsin Wyoming
Zip
Phone
Fax
Contact Name
Potential Effective Date JANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDEC 12345678910111213141516171819202122232425262728293031 2012201320142015
Email Address:
Web Site Address: http://
Group Name
Group Number
Number of Employees
Network Access YES NO
Name
Comment on Specific Carve Outs:
Reinsurer Notification Requirements:
Utilization Management
Case Management
Medical Claim Review
Disease Management
All Products and Services
Disability Management
Wellness Initiatives
Independent Review
Population Management
Inpatient Review
Outpatient Review
Network Steerage
Second Surgical Opinion
All Services
