Get Request For Average Age/average Factor Adjustment Form

The Request For Average Age/Average Factor Adjustment Form is a crucial document for community-rated renewal groups with BlueChoice and/or BluePreferred. This guide provides comprehensive, step-by-step instructions to help users complete the form accurately and efficiently online.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Indicate whether you are requesting an evaluation for average age or average factor adjustment by checking the appropriate box at the top of the form.
3. Complete the group information section, providing details such as GROUP#, GROUP NAME, RENEWAL STATE, RENEWAL DATE, REVISED AVG AGE, and NEW HIRE ELIGIBILITY PERIOD.
4. For the ADDITIONS section, list any new enrollees by filling out their SSN, NAME, DOB, AGE, DOH, EFF DATE, C/M, FULL/PART time status, and 1099 information as applicable.
5. In the TERMINATIONS section, document any subscribers being canceled, including their SSN, NAME, TERM DATE, and the REASON FOR TERMINATION using the provided codes.
6. In the CHANGES/CORRECTIONS FOR EXISTING SUBSCRIBERS section, note any adjustments that will impact the average age, including changes such as DOB corrections or changes in medicare coverage.
7. For OTHER CHANGES, provide any additional information that may impact the renewal average age, such as medical underwriting or MSGR county code adjustments.
8. Once you have filled out the form completely, save your changes. After that, you may download, print, or share the form as needed.

Take the next step in your document management by completing your forms online today.