This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines CalCPA’s case submission requirements. This enrollment kit applies only to groups of 2-199 lives.
- Subscription Agreement - Effective 1/1/2019
- A copy of the latest DE-9C
- Employee Enrollment Forms from all employees enrolling
Applications from all Qualified Beneficiaries applying for COBRA coverage
- Applications from all employees/dependents declining coverage; Sections 2 and 8 of the employee application must be completed.
- A Medicare Secondary payer Survey must be submitted if any employees are eligible for Medicare.
Prior carrier EOB(s) for the employees who are eligible for deductible credit from another carrier. Requests for deductible credit must be submitted to Banyan Administrators, LLC with the enrollment form at the time the firm enrolls in the plan. Claims processed by the carrier after the firm’s application is submitted may be credited if the plan member submits the prior carrier’s EOB(s) to Banyan Administrators, LLC within 30 days of the date that the prior carrier paid. Eligible deductible credits may be transferred from a previous Anthem plan upon request and do not require EOBs.
If an employee is choosing an HSA plan, the form for Mellon Bank or US Bank must be completed: ProtectPlus HSA Authorization Form . If the employee is using another HSA account provider, please indicate there is no interest in Mellon or US Bank.
- Be sure HMO enrollees select an IPA or PMG (CalCPA Provider Search ) and write in the provider code number on each HMO enrollee's enrollment form. If no provider code is indicated or an incorrect provider code is entered, Anthem will automatically assign one based on the employee zip code.
- Effective date is the first of the month only. Applications must be received by Banyan Administrators, LLC on or before the 5th of the month in which coverage is to be effective. If the 5th of the month falls on a weekend or a holiday, then the submission deadline is the first subsequent regular workday.
- Producer Agreement completed and signed
- Copies of insurance license and E&O coverage
- Review all forms to make sure they are completed. Applications must be completed in the applicant’s own handwriting.
- Include a copy of the quote.
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful or older documents, please refer to the Forms database.
Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website. For the most recent information regarding CalCPA’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.