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["Administrative Data","The QHP Application requires submission of certain administrative data that will be utilized for operational purposes. This information includes identifying information and contact information. "]
["Go to cell B1 for instructions","Some of this information will be pre-populated based on the information you have previously entered in HIOS.                "]
[null,"All fields marked with an asterik (*) are required. Depending on the Proposed Exchange Market Coverage selected, certain additional fields may be required.  "]
[null,"On validation, missing or incorrect data is highlighted."]
[null,"To validate the template, use the Validate button or press Ctrl + Shift + V. To finalize the template, press the finalize button or press Ctrl + Shift + F."]
["Issuer ID:*",null,"Proposed Exchange Market Coverage:*"]
["Issuer State:*",null,"Current Sales Market:*"]
[]
["1. Administrative Data "]
["Company Legal Name:*","Issuer Legal Name:*","Issuer Marketing Name:*"]
[]
[]
["Associated Health Plan ID:","TIN:*","NAIC Company Code:","NAIC Group Code:"]
[]
[]
["2. Company Address "]
["Address:*","Address 2 (optional): ","City:*","State:*","Zip Code:*"]
[]
[]
["3a. Issuer Address"]
["Address:*","Address 2 (optional): ","City:*","State:*","Zip Code:*"]
[]
[]
["3b. Issuer Billing Address"]
["Address:*","Address 2 (optional): ","City:*","State:*","Zip Code:*"]
[]
[]
["4. Select Your Primary Contact:*"]
[]
[]
["5. Issuer Individual Market Contact"]
["First Name:","Last Name:","E-mail Address:","Phone Number: ","Phone Extension: "]
["","","","",""]
[]
["6. Issuer SHOP (Small Group) Contact"]
["First Name:","Last Name:","E-mail Address:","Phone Number: ","Phone Extension: "]
[]
[]
["7. CEO"]
["First Name:* ","Last Name:* ","E-mail Address:* ","Phone Number:* ","Phone Extension: "]
[]
[]
["8. CFO "]
["First Name:* ","Last Name:* ","E-mail Address:* ","Phone Number:* ","Phone Extension: "]
[]
[]
["9.  Customer Service - Individual Market "]
["Customer Service Phone:","Customer Service Phone Extension: ","Customer Service Toll Free:","Customer Service TTY:","Customer Service URL:"]
["","","","",""]
[]
["10.  Customer Service - SHOP (Small Group)"]
["Customer Service Phone:","Customer Service Phone Extension: ","Customer Service Toll Free:","Customer Service TTY:","Customer Service URL:"]
[]
[]
["11.  Contacts"]
["Contact Type","First Name","Last Name","Phone Number","Extension","E-mail Address"]
["Enrollment Contact"]
["Online Enrollment Center Contact (Primary)"]
["Online Enrollment Center Contact (Backup)"]
["System Contact"]
["Appeals/Grievances Contact"]
["Customer Service Operations Contact"]
["User Access Contact"]
["Backup User Access Contact"]
["Marketing Contact"]
["Medical Director"]
["Chief Dental Director"]
["Pharmacy Benefit Manager"]
["Government Relations Contact"]
["HIPAA Security Officer"]
["Complaints Tracking Contact"]
["Quality Contact"]
["Compliance Officer"]
["Payment Contact"]
["APTC/CSR Contact"]
["Financial Reporting Contact"]
["Financial Transfers Contact"]
["Risk Corridors Contact"]
["Risk Adjustment Contact"]
["Reinsurance Contact"]
[]
["12. Third Party Administrator(s):"]
["Do you have a TPA for the following processes:"]
["Enrollment*"]
["Claims Processing*"]
["Edge Server Host*"]

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