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Current As Of
"Current As Of" signifies the latest date on which a Word & Brown
Team Member confirmed that the Forms/Document available for download represents the most up-to-date and recently
revised version accessible.
PLEASE NOTE: 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 lists outlines Prominence Health Plan's case submission requirements.
Completed Large Group (51+) Master Application
Census enrollment or completed enrollment forms for all employees with requested information about their enrolling dependents. If providing via census enrollment, please contact your PHP account executive for an approved census format. Important to note:
Employees who are waiving coverage must complete form sections A and H. If an employee is waving due to coverage elsewhere, a copy of the other carrier ID card must be provided.
For member dependents with different last names than member, PHP will require additional documentation to connect members to his/her dependents. In some cases both a marriage certificate and birth certificate may be necessary. Member will have 30 days from the start of the coverage to provide this information before coverage will term back to the effective date of coverage.
To avoid delays in processing an HMO member, HMO applicants MUST select an approved PCP during initial enrollment.
For groups electing to cover Domestic Partnership – A Certificate of Registered Domestic Partnership from the state is required when member is enrolling for domestic partners. If the domestic partner has not registered with the state, coverage for the domestic partner will take effect on the date the Certificate of Registered Domestic Partnership is approved by the state.
Employer Check for the first month's premium made payable to "Prominence Health Plan."
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.
For other useful or older documents, please refer to the Forms database.