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Health Benefit Representative Contact and Access Request

The role of a Health Benefits Representative (HBR) is defined in Article 3B of Chapter 135 of the North Carolina General Statute: § 135 48.1.(13). All HBRs are expected to view the training materials available on the State Health Plan’s website to fully understand those responsibilities and requirements. To view all training materials, click here.

If the training materials have been reviewed, please complete the below form:

Type of Request Being Submitted

*

General HBR and Group Information

First Name

**

Group Name

*

Last Name

**

Mailing Address 1

**

Title

**

Mailing Address 2

*

Email Address

***

Mailing City

**

Primary Phone Number

**

Mailing State Abbreviation

**

Secondary Phone Number

*

Mailing ZIp Code

**

System Access Requested:

Benefits Eligibility and Enrollment Access?

*

Benefits Eligibility and Enrollment Access? No Benefits Eligibility and Enrollment Access? Yes

Premium Billing Access

*

Premium Billing Access NoPremium Billing Access Yes

Subject Matter Contact Areas for Your Group?

ACA Reporting

*

ACA Reporting NoACA Reporting Yes

Group Escalation Contact

*

Group Escalation Contact NoGroup Escalation Contact Yes

Access/Contact Request Approver

*

Access/Contact Request Approver NoAccess/Contact Request Approver Yes

Premium Billing

*

Premium Billing NoPremium Billing Yes

Dependent Audit

*

Dependent Audit NoDependent Audit Yes

Recovery and Wage Garnishment

*

Recovery and Wage Garnishment NoRecovery and Wage Garnishment Yes

Exceptions

*

Exceptions NoExceptions Yes

Previous Contact(s) You are Replacing for Your Group:

Are you replacing anyone?

*

Are you replacing anyone? NoAre you replacing anyone? Yes

If yes, replacing who?

*

Request Approver Information
(must be Manager or Higher Level Person from your Group)

Your Group's Access/Contact Approver Name

**

Access/Contact Approver Email Address (used to contact the approver for validation)

**

Access/Contact Approver Title

**

Please provide any information that will help process this request:

*

Submit

By Clicking 'OK' below you are confirming that you have completed the review of training materials on the State Health Plan website and all items below are true:

1. The role of a Health Benefits Representative (HBR) is defined in Article 3B of Chapter 135 of the North Carolina General Statute: § 135 48.1.(13). All HBRs are expected to view the training materials available on the State Health Plan’s website to fully understand those responsibilities and requirements. To view training materials go to this website: State Health Plan Training and Development

2. That you understand that this form is only for Groups requesting NC State Health Plan benefit administration system access or are in a role that is related to supporting the Plan on behalf of their Group's employees.

3. You are a current employee of the Group selected and are actively working in the role(s) selected on this form.

4. You agree to be included on the Plan's email list to receive HBR Updates/Alerts.

If you have not completed the review of training materials and/or all items above are not true, please cancel out of this form to complete those tasks before submission.

To view the Privacy Practices of the NC State Health Plan please visit the link below:

https://www.shpnc.org/notice-privacy-practices