Anthem blue cross blue shield

Enrollment Kit - Anthem BCBS (dental)

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 prov​​​​ide you and your client with a quick approval.  The following list outlines Anthem Blue Cross Blue Shield's case submission requirements.
 
  • ​​​Employer Enrollment ApplicationPlease ensure all fields within the application are completed, signed and dated. Incomplete applications may be returned, which could delay the processing of your application. 
  • ​​Employee Enrollment Form(s) for each eligible employee/dependent enrolling and/or declining coverage. Employees/dependents waiving coverage only need to complete Sections A and F.
  • All signatures and dates must be included and cannot be more than 60 days before the requested coverage effective date. 
  • Enrolling employees who wish to decline coverage for their spouse or children must  complete Section F of the application.
  • No payroll information is necessary for standalone dental. Payroll information is required for dental sold with medical only.​
  • ​​The last billing statement listing COBRA/FMLA, if applicable. 
  • A completed Electronic Funds Transfer (EFT) Authorization Form for 100% of the first month's premium made payable to Anthem Blue Cross and Blue Shield. 
  • A 1099 Addendum - applicable for 1099 individuals. 1099 contractors are eligible for coverage with the following requirements: 
    • ​No more than 50% of the group's insurance eligible population can be 1099 contractors.
    • 1099 employees are not eligible for vision or life benefits. 
    • All present and future 1099 contractors are subject to the same eligibility requirements as taxed employees.
    • The employer must contribute the same amount for 1099 contractors as for all other employees qualifying under NRS 689C. ​
    • The employer must have at least one taxed employee, with tax documents that verify the company is a valid business. 
    • The new group submission must include a complete list of all 1099 contractors, four weeks of current payment documenting active FT 1099 status, and a completed Eligibility Requirements Form for Groups Covering 1099 Contractors (Addendum Form). 
  • Certificate of Domestic Partnership from the State is required when group is enrolling and offering coverage for Domestic Partners. ​
  • Completed New Producer Sub Agreement
Licensing:  Broker appointment must be completed online via this link.  NOTE:  The group will not be approved until licensing is received.
 
​After approval, prior carrier termination letter must be submitted by the employer or broker. 
 
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 Anthem’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.
For other useful or older documents, please refer to the Forms database.
  • Eligibility Requirements for Groups Covering 1099 Employees
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 01.01.2015

  • New Producer Sub Agreement
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 05.01.2017

  • Electronic Funds Transfer (EFT) Authorization Form
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 09.01.2020

  • New Group Submission Checklist - Ancillary
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 10.01.2020

  • Employer Application (All Coverage)
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 01.01.2021

  • Employee Enrollment Application
    • Anthem Blue Cross Blue Shield

    • form # N/A

    • Effective date: 01.01.2021