Enrollment Submission

New Enrollment Submission

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PDF Documents

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Enrollment PDF required

Signed enrollment form · auto-extracts fields

Plan SOB required

Summary of Benefits · fills Plan Benefits sheet

Client & Plan required

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Client name

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MBI

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New Plan Name

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Old plan

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SF Code

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Team Notes for Sale

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Selling Point / Why This Plan Is Better

Call Notes required

Medicaid Number

Medicaid Level

LIS Level

HRA Completed

Doctors In / Out of Network

Total Doctors Seen

In-Network

Medications Covered

Total Medications

Covered by Plan

Client Services Needed D-SNP / C-SNP only

Summary auto

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