You’re offline. This is a read only version of the page.

Home
Submit New Exception
Submit HBR Access/Contact Request
Sign in

Health Benefit Representative Contact and Access Request

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 the following is true:

1. 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.

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

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

Health Benefit Representative Contact and Access Request

Type of Request Being Submitted

General HBR and Group Information

System Access Requested:

Subject Matter Contact Areas for Your Group?

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

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

Please provide any information that will help process this request:

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

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

Health Benefit Representative Contact and Access Request

Type of Request Being Submitted

General HBR and Group Information

System Access Requested:

Subject Matter Contact Areas for Your Group?

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

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

Please provide any information that will help process this request:

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

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

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

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