Presbyterian

Health Plan, Inc.

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Home|Employers & Producers|Forms and Resources|Employer and Producer Forms and Documents

Coverage That Makes Sense

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

Producer Commissions Authorization/Agreement for Direct Deposit Presbyterian Senior Care Table of Commission Rates New Group Enrollment Checklist Regular Small Group Information Sheet Regular Employee Action Form Regular Exhibit B Regular

Guidelines

Field Underwriting Guidelines (Group)

Forms

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

Questions and Answers

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

Presbyterian Group Benefit Information

Benefit Briefs

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

Procedural Forms

Forms for Quoting a Group with Presbyterian

Rate Request Form Census Form UMAF Medical Assessment Form/English UMAF Medical Assessment Form/Spanish

Forms for Enrolling a Group with Presbyterian

Enrollment Checklist Employer Group Information Sheet Employee Action Form PIC/PHP (enrollment /change /waiver) Spanish Employee Action Form PIC/PHP (enrollment /change /waiver) PHP Individual Assessment Form PIC Individual Assessment Form Exhibit B, Bank Draft Authorization (Required for Groups 2-9) PEO/Leased Employee Verification Form Transition of Care Form

Individual Plans

Presbyterian's Individual and Family Plans Individual Enrollment Application

Rates

Active Plan Rate Sheets

Rate Sheet for Albuquerque Counties Rate Sheet for Santa Fe Counties Rate Sheet for Las Cruces and Farmington Counties Rate Sheet for All Other NM Counties

Individual Plan Member Forms

Individual Member Add Dependent Form Individual Member Termination Form

Questions?

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