State of Vermont Registration Form
Vermont Healthcare Claims Uniform Reporting and Evaluation System


Under Vermont law, all insurers providing health-related services for comprehensive major medical benefits, Medicare supplement, Medicare Part C, and/or Medicare Part D to any Vermont residents are required to register here with Onpoint Health Data.

Third party administrators and pharmacy benefit managers are also required to register to meet the Vermont TPA and PBM annual registration requirement. The annual registration renewal cycle has a deadline of December 31. No registration fees are required. The consolidated form below is designed to support VHCURES, TPA, and PBM registration. Since partially completed forms cannot be saved, you may want to print a copy of the blank for review before starting the on-line registration.

1.  Type of Submitter
      Insurance Company
      Pharmacy Benefit Manager
      Third Party Administrator


2.   Company Information
Company Name
Mailing Address
City
 State
 Zip Code
Country
NAIC            FEIN

3.   Does your company currently conduct health insurance related business for 200 or more residents of the state of Vermont in any of the following types of insurance including comprehensive major medical, Medicare Part C, Medicare Part D, Medicare supplement?
      Yes
      No

4.   Please complete the section below regarding the eligibility data your company will be submitting and the appropriate contact person. Enter 0 if there are no lives.
  MedicalPharmacy
Estimated Number of Major Medical Vermont Covered Lives for 1 Month
Estimated Number of Medicare Part C Vermont Covered Lives for 1 Month
Estimated Number of Medicare Part D Vermont Covered Lives for 1 Month
Estimated Number of Medicare Supplemental Covered Lives in 1 Month
Contact First Name
 Contact Last Name
 Phone:
Title:
Email Address
 Fax:
Company Name
Mailing Address
City
 State
 Zip

5.    Will your company be submitting medical claims data? If yes, enter the additional information in the boxes below.
      Yes
      No
Estimated number of medical claims paid per month.
Estimated total dollar amount of medical claims paid per month.
The contact person for Medical is the same as the contact for Eligibility.
Contact First Name
 Contact Last Name
 Phone
Title
Email Address
 Fax
Company Name
Mailing Address
City
 State
 Zip

As part of the delivery of data to the state of Vermont under this contract, Onpoint Health Data is required to deliver a fully consolidated, incurred claims data set. Therefore we would like to have you explain what claims consolidation method will be required to take your paid claims data sets for a given time period and consolidate them into a detail claim line transaction set that accurately represents the current incurred claim payment status. Please provide this information below or via a separate email.

Typical consolidation methods include (a) the use of the version number field, where the highest version number of any detail claim line or claim should be considered the latest incurred payment status, and (b) a straight roll-up method with quantity and dollar data elements summed if all adjustment claim lines are present.

It often is helpful if someone in your organization who deals directly with claims processing and/or data warehousing answers this question. If you have questions about what is being requested, please contact Onpoint by email or phone (207-623-2555).

6.   Will your company be submitting pharmacy claims data? If yes, enter the additional information in the boxes below.
      Yes
      No

Estimated number of pharmacy claims paid per month.
Estimated total dollar amount of pharmacy claims paid per month.

The contact person for Pharmacy Claims is the same as the contact for
Eligibility
Medical

Contact First Name
 Contact Last Name
 Phone
Title
Email Address
 Fax
Company Name
Mailing Address
City
 State
 Zip

7.   Person Completing This Form
      The person completing this form is the same contact as
        Eligibility
        Medical
        Pharmacy

First Name
 Last Name
 Phone
Title
Email Address
 Fax
Company
Mailing Address
City
 State
 Zip

8.   Compliance Contact
     The Compliance Contact is the same contact as
        Eligibility
        Medical
        Pharmacy
        Person Filling Out Form

First Name
 Last Name
 Phone
Title
Email Address
 Fax
Company
Mailing Address
City
 State
 Zip

 

9.   TPA/PBM Information
Domicile (U.S.) State of Incorporation
Domicile (Outside of U.S.)
DBA/Trade Name (if applicable)
Parent Company Name
Parent FEIN #
Parent NAIC #

 

10. Did the company provide administrative services for a health line of business for any Vermont residents within any of the listed health lines for any given month within the most current business year? (Check all that apply)
      Comprehensive Major Medical
      Pharmacy
      Medicare Supplemental (Medigap)
      Behavioral Health
      Substance Abuse
      Long Term Care
      Disability
      Dental
      Other Medical (Non-comprehensive)
      Specified Named Disease
      Limited Benefit
      Student Policy
      Worker's Compensation
      Accident Only or AD&D
      Stop Loss
      Vision
      Other

  

11. Does the company provide the following business services for plan sponsors, insurers or other entities providing benefits for the following health lines of business?
Business ServicesComprehensive
Major Medical		 PharmacyBehavioral
Health		Medicare
Supplement		 Other
Collect & Handle Premiums
Adjust Claims
Pay Claims
Utilization Review

12. List all plan sponsors that are entities that have self-funded ERISA plans that include any Vermont residents. Check all health lines of business that apply for each plan sponsor.

Please indicate whether you consider the list to be competitively sensitive proprietary information to be treated as confidential by the Department:
Plan Sponsor Name Comprehensive
Major Medical		 Pharmacy Behavioral
Health
A. 
B. 
C. 
D. 
E. 
F. 
G. 
H. 
I. 
J. 
K. 
L. 
M. 
N. 
O. 

 

10. Do you perform pharmacy benefit management for individuals enrolled in a health plan in which coverage of prescription drugs is administered by a PBM and includes their dependents or other persons provided health coverage through that health plan, per 18 V.S.A § 9471?
Yes
No

11. Do you perform pharmacy benefit management for a health benefit plan offered, administered, or issued by a health insurer doing business in Vermont? For these purposes, “health insurer” includes a health insurance company, a nonprofit hospital and medical service corporation, and health maintenance organizations as well as an employer, labor union, or other group of persons organized in Vermont that provides a health plan to beneficiaries employed or residing in Vermont, per 18 V.S.A. §9471?
Yes
No

12. Check any pharmacy benefit management services that you provide for Vermont residents or employees. (Check all that apply)

Mail service pharmacy
Claims processing
Retail network management
Payment of claims to pharmacies for prescription drugs dispensed to beneficiaries
Clinical formulary development and management services
Rebate contracting and administration
Patient compliance, therapeutic intervention, and generic substitution programs
Disease or chronic care management programs.
Other:

13. List all carriers and government insurers and payers covering any Vermont resident that are contracting with your company for third party administration business services in any of the lines of business.
Please indicate whether you consider the list to be competitively sensitive proprietary information to be treated as confidential by the Department:
A.  B. 
C.  D. 
E.  F. 
G.  H. 
I.  J. 
K.  L. 
M.  N. 
O.  P. 
Q.  R. 
S.  T. 

Comments:

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