HealthiestYou - New Group Set Up Form - Brewers Association

New Employer SetUp Form

Employer Information

HealthiestYou Complete Bundle (All Consults Included)

Employer Name*

Effective Date (MUST be 1st of the month)*

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Phone*

How many employees do you expect to enroll?*

Note: If the actual number of employees in the eligibility file at implementation is less than ninety percent (90%) of the number entered then the Fee may be increased by $2.00 PEPM.

Group Administrator Information

GROUP ADMINS: You can perform administrative functions for your group online with up to 2 people designated as administrators. Administrators have full access to add/change/terminate employees, view or modify non‐medical member data and view invoice status.

Admin 1 Name*

First Name

Last Name

Admin 1 Email Address*

Admin 1 Phone Number*

Admin 2 Name

First Name

Last Name

Admin 2 Email Address

Admin 2 Phone Number

Billing & Contract Information

Invoices will be generated on the first of each month and sent electronically to the group administrator(s) listed above unless a separate billing contact is listed below.

Is the billing contact the same as the group administrator?*

Yes No

Billing Contact Name*

First Name

Last Name

Billing Contact Email Address*

Billing Contact Phone Number*

Is the contract signee contact the same as the billing administrator?*

Yes No

Contract Signee Contact Name*

First Name

Last Name

Contract Signee Contact Email Address*

Contract Signee Contact Phone Number*

Eligibility Submission Method

Eligibility may be submitted via a one-time census spreadsheet file upload or can be manually entered into the Client Portal.

When choosing Client Portal, credentials and instructions will be provided to the Group Administrator listed on page 1.

When choosing One Time Census Spreadsheet (MFT), credentials and instructions will be provided to the Eligibility/IT Contact(s) provided in this section.

Additionally, certain eligibility may require an ongoing file transfer method (EDI feed). EDI feeds are typically established for groups with 50 employees or more that require frequent updates on a regular basis.

New groups that are submitted after the 1^st of the month for the current month’s effective date must select and provide eligibility via One Time Census Spreadsheet (MFT) - (e.g. submitted on 12/5 for 12/1 effective date).

Method of Submitting Eligibility:*

Manual Entry via Client Portal (suggested for 25 employees or less) One Time Census Spreadsheet (MFT) Ongoing EDI Feed

Client Portal Eligibility Contact

Instructions for client portal manual entry will be sent to this contact

Who will be entering the eligibility information?*

Eligibility Contact Name*

First Name

Last Name

Eligibility Contact Email Address*

Eligibility Contact Phone Number*

Primary IT/Eligibility Contact Information

Instructions for file transfer process will be sent to this contact

Eligibility Contact Name*

First Name

Last Name

Eligibility Contact Email Address*

Eligibility Contact Phone Number*

EDI Feed Contact Information

Instructions for EDI feed layout and transfer process will be sent to this contact

Eligibility Company Name*

Eligibility Contact Name*

First Name

Last Name

Eligibility Contact Email Address*

Eligibility Contact Phone Number*

Submitter Information

A confirmation email of this form will be sent to this contact.

Submitter Name*

First Name

Last Name

Submitter Email*