DOCUMENTS THAT CONTAIN WHITE-OUT CANNOT BE ACCEPTED

Administrative Form

Section Line# / Description /

Instructions

Group Number: To be completed by BlueCross BlueShield of Tennessee
Effective Date: To be completed by BlueCross BlueShield of Tennessee
Section A - General Information
1 / Group Name / Name of group is listed here, including dba name.
2 / Physical Location / Complete ‘if’ different than mailing address. This is the physical location of the group.
3 / Billing Address / Complete ‘if’ different than mailing address. This is the address where bills are to be sent.
4 & 4a / Telephone Number / Extension / Group's telephone number and extension.
4b / Fax Number / Group's fax number.
5 / Nature of Business / Detailed description of business.
6 / Current Group Medical Carrier / Who is the current medical carrier?
6a / Current Group Dental Carrier / Who is the current dental carrier?
6b / Current Group Vision Carrier / Who is the current vision carrier?
7 / Union-negotiated contract / Answer yes or no. If yes, enter expiration date.
7a / Minority ownership / Answer yes or no.
7b / Government contractor / Answer yes or no.
8 / What is employer's fiscal year? / List fiscal year – begin month and date and end month and date (ie: 01/01-12/31). Do not enter year.
9 / When does employer’s ERISA plan year begin? / List begin month and day of plan year (ie: 04/01). Do not enter year.
10 / Creditor filed request for employer bankruptcy (in past 36 months) / Answer yes or no.
11 / Employer filed bankruptcy (in past 36 months) / Answer yes or no.
12 / Sole proprietorship question. / Answer yes or no. If ‘yes’, then answer following question.
13 / Who can make changes via Web (Blue Access & e-Health Services) for Employee Addresses, Coordination of Benefits and Enrollment? / Check Group, Employee and/or Broker for each one.
14 / Initial ID card mailing / Where are initial ID cards to be mailed?
15 / Future ID card mailing / Where are any future ID cards to be mailed?
16 / Notes / Enter additional notes.
Section B – Contact Information
1 / Name of Group Administrator / Enter name of Group Administrator.
1a – 1e / Group Administrator Contact Information / Enter Group Administrator title, phone, extension, fax number and email address.
2 / Name of Executive Decision Maker / Enter name of Executive Decision Maker or check “Same as Group Administrator” box. Skip 2a-2d if same as Group Administrator is checked.
2a – 2d / Executive Decision Maker Contact Information / If different than Group Administrator, enter Executive Decision Maker title, phone, extension number and email address.
3 / Name of Eligibility Contact / Enter name of Eligibility Contact or check “Same as Group Administrator” box. Skip 3a-3c if same as Group Administrator is checked.
3a – 3c / Eligibility Contact Information / If different than Group Administrator, enter Eligibility contact phone, extension number and email address.
4 / Name of Billing Contact / Enter name of Billing Contact or check “Same as Group Administrator” box. Skip 4a-4b if same as Group Administrator is checked.
4a – 4b / Billing Contact Information / If different than Group Administrator, enter Billing contact phone and extension number.
4c / Billing Contact Email Address / Billing email address is required for electronic billing. Paper bills will not be sent.
Section C – Plan Eligibility
1 / Does Employer have any group coverage with BCBST. / Answer yes or no.
Current group number or name / If 1 is answered yes, enter current group number or name.
2 / Employer contribution / Enter employer’s contribution for medical, dental and/or visionblue.
3 / Requested Billing Cycle / Enter group’s requested bill cycle, if it is different from the effective date (ie: 01/15).
Employee Grid: Enter number of Employees eligible, enrolling in and waiving coverage at the effective date of this coverage for each class indicated.
Section D – HRA / FSA / HSA - Skip this section if not applicable.
1 / Answer yes if employer is offering a BCBST HRA plan.
2 / Answer yes if employer is offering a BCBST FSA plan.
3 / If HSA selected, is Employer contributing to a HSA / Check yes or no
3a / HSA Bank Selection / If HSA selected, check one. Indicate HSA Bank selection if ‘other’ is checked.
Section E – Broker Information
1 / Primary Broker’s BCBST ID / Enter primary broker’s BCBST ID (SSN or Tax ID)
2 / Co- Broker’s BCBST ID / Enter co-broker’s BCBST ID (SSN or Tax ID)

Broker Instructions – Administrative Form

Revised 06/13 1