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Group Health Benefit Representative Access and/or
Contact Request Submissions

Health Benefit Representative 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 if access to the Benefits Eligibility and Enrollment and/or Premium Billing platform are needed.

Group Subject Matter Contact Request:
The NC State Health Plan has a need to have subject matter contacts for multiple business areas of a Group. The form below should be submitted for group subject matter area contacts.

Please note: This form is not intended to be used by employees who need to enroll in benefits - only for Benefit Administrators or Group Health Plan Contacts.

Type of Request Being Submitted

General HBR and Group Information

First Name

Group Name

Last Name

Mailing Address 1

Job Title

Mailing Address 2

Email Address

*Please ensure that the email address entered is correct before submission.

Mailing City

Primary Phone Number

Mailing State Abbreviation

Secondary Phone Number

Mailing ZIp Code

System Access Requested:
(only select access required to perform job duties)

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

Exceptions

Exceptions NoExceptions Yes

Subscribe to HBR Alert

Subscribe to HBR Alert NoSubscribe to HBR Alert Yes

Access/Contact Request Approver

Access/Contact Request Approver NoAccess/Contact Request Approver Yes

Group Escalation Contact

Group Escalation Contact NoGroup Escalation Contact Yes

Benefits Eligibility and Enrollment

Benefits Eligibility and Enrollment No Benefits Eligibility and Enrollment 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

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 and/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 subject matter contact 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