Enrollment Kit - UnitedHealthcare (Medical)
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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 UnitedHealthcare’s case submission requirements.
- Small Business Employer Application
- Product and Benefit Selection Form
- Written Assurance form required for groups who select No to ERISA and select either Church or Foreign Government/Foreign Embassy as the ERISA category on the Employer Application
- Church groups must also provide the IRS Form 941 or 940
- All proof of business documents. Proof of ownership is required for all eligible owners who do not appear on the DE 9C (Enrolling or waiving).
- Most recent DE 9/DE 9C
- Tax documents for owners not on the DE 9C.
- Payroll
- PRIME Enrollment Spreadsheet
OR
- Employee Applications/Waiver Forms
- When you submit the UnitedHealthcare enrollment, put in DE 9/DE 9C order with HMO subscribers grouped together, and Select/Select Plus, HRA and HSA subscribers grouped together
- List owners first if not listed on DE 9/DE 9C
- COBRA and new hires go to the back, if not listed on the DE 9/DE 9C
- Handwrite new hires on the last page of the DE 9/DE 9C. Include the following information: Date of hire, social security number, complete first and last name
- SAM Quote
- Binder Check or Direct Debit Form. Please note: Micro groups (under 3 eligible or 1 enrolled) are required to use the ACH form.
- Completed and signed Participation Certification form for Employers with 10+ eligible employees
- Primary Business Location is where the business has filed their Articles of Incorporation. If PBL is not in California, Certificate of Incorporation must be completed with submission.
- For Prior Carrier Deductible: Prior carrier deductible Report or EOBs from prior carrier for all members on the group will be required.
- Broker licensing is required at the time of case submission.
- Paper billing -or-
- Electronic billing
- Would your HSA group like to utilize Optum Bank services for their HSA banking needs?
- Ensure that ERISA is always marked "Yes". Only churches and specialized non-profits can be marked "No".
- Cal-COBRA marked, if under 20
- COBRA marked, if over 20
- Confirm group email address is the administrative email address, not executive email address
- Please submit single-sided copies of the application, not double-sided
- Please list total member count including dependents on the case submission cover sheet
- Confirm COBRA participants are listed on the Small Business Employer Application
| 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 UHC’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.