Presbyterian Health Plan, Inc. wants to help. Below are documents that are frequently requested. If you can't find what you are looking for, please contact us.

General

• Presbyterian Senior Care Table of Commission Rates
• Producer Commissions Authorization/Agreement for Direct Deposit

Guidelines

• Field Underwriting Guidelines (Group)

Forms

• HIPAA - General Release of Information Form: Member/Subscriber
• Medicare Sales Appointment Confirmation Form
• Member Termination/Change Form (for groups only)
• My Care Unique Service Reimbursement Form

Questions and Answers

• 4-Tier Prescription Drug commonly asked questions
• Commonly asked questions about non-par providers (R&C, DDs etc)

Presbyterian Group Benefit Information

Small Group Application Kit

• 2018 Small Group Application Kit

Benefit Briefs

• PresElect Plans (Group size 2-50 PPO)
• Smart Care Plans (Group size 2-50 HMO)
• Value Care Plans (Group size 2-50 HMO)
• Vantage Care Plans (Group sizes 2-50 and 51+ HDHP, qualified HSA plans)
• Custom Care Plans (Group size 51+ HMO)
• Preferred Care Plans (Group size 51+ PPO)
• Smart Care Plans (Group size 51+ HMO)

Procedural Forms - Quoting a Group with Presbyterian

• Census Form
• Large Group UMAF
• Rate Request Form
• UMAF Medical Assessment Form, English
• UMAF Medical Assessment Form, Spanish

Procedural Forms - Enrolling a Group with Presbyterian

• Employee Action Form, English
• Employee Action Form, Spanish
• Employee Action Form PIC/PHP, Spanish (enrollment /change /waiver)
• Employer Group Information Sheet
• COBRA
• Transition of Care Form

Individual Plans

• Presbyterian's Individual and Family Plans

Questions?

• Call our knowledgeable associates on our Employer/Producer hotline:
• 505-923-5656 or 1-866-246-9877