RFP Intake Form


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Plan Type
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If a Network Disruption Analysis is requested, you must submit the following report criteria in Excel:


  • Provider Name
  • Provider TIN #
  • City
  • State
  • Zip
  • Claim Amount
  • Provider Type
Can you confirm a call with the decision makers?
  • Census- Must have dependent info on separate rows from subscriber and include all of the following fields: Name, DOB, Relationship, Gender, Street Address, City, State, Zip, Tier (EE, ES, EC, FAM, WAIVE), Plan Choice, Active/COBRA/Retiree
  • Current SPD/SBC
  • Monthly Claims- Current & Prior Plan Year
  • Large Claims
  • Rx Claims
  • Top Drugs Report
  • Current Renewal
Drag and drop files here or