Fillable Form Approved: Instructions to help you complete the (Centers for Medicare & Medicaid Services)

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Form Approved: Instructions to help you complete the (Centers for Medicare & Medicaid Services)

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Instructions to help you complete the
SHOP Employer Eligibility Appeal Request
Use the right
form to request
an appeal
• This form is for employers that applied to participate in the Small Business
Health Options Program (SHOP) Marketplace.
• If you were denied eligibility to participate as an employer in the federally-
facilitated SHOP Marketplace, you can request an appeal.
• If your business isn’t eligible to participate in SHOP, you can re-apply on a
monthly basis.
• Some states operate their own SHOP. If you’re not sure this form is the right
one for you, visit HealthCare.gov/small-businesses/ to learn more about your
state’s SHOP.
• Visit HealthCare.gov/marketplace-appeals to learn more about Marketplace
appeals.
Timeframe to
request an appeal
We must receive your appeal request within 90 days of the date on the SHOP
eligibility determination notice that you’re appealing.
How to submit
this form
Complete and sign this form, and mail it with copies of any supporting
documents to:
SHOP Marketplace Appeals
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
Or, fax the form and documents to a secure fax line: 1-877-369-0131.
Keep a copy of all forms for your records.
How to submit
additional
information
You may submit additional information along with this Appeal Request Form to
support your appeal. Send copies only. Keep all original documents. We’ll consider
all timely information when making a nal determination. Submit all available
information when you send this Appeal Request Form.
What happens
next?
1. We’ll contact you. We’ll send a notice to let you know that we got your
appeal request. It will explain the appeal process, and give you instructions
for sending additional information, if needed. You’ll have 15 days from the
date of this notice to send any additional information if it’s required. If there’s
a problem with your appeal request, like if it’s missing information, we’ll tell
you how to correct the issue. We’ll also tell your employer about your appeal
request. Your employer can submit information to support your appeal.
2. We’ll review your information. Your appeal request will be reviewed along
with the information used by the SHOP Marketplace to determine your
eligibility.
3. We’ll send a decision about your appeal. A final decision will be mailed to
you within 90 days when we get your appeal request.
10/2018
Form Approved
OMB No. 0938-1213
SHOP Appeal Request Form – Employer
Additional
help
Language assistance services
If you need help requesting an appeal in a language other than English, you
have the right to get help and information in your language at no cost. Call
the Marketplace Appeals Center at 1-855-231-1751. Hours of operation are
Monday through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET).
Accessibility
To request appeal forms and notices in an alternate format like Braille, large print,
data CD, audio CD, or to request a qualified reader, you can call the Marketplace
Appeals Center at 1-855-231-1751. TTY users can call 1-855-739-2231. Hours of
operation are Monday through Friday, 7:00 a.m. to 8:30 p.m. Eastern Time (ET); and
Saturday, 10:00 a.m. to 5:30 p.m. ET. You can also make a request in writing by fax
(1-877-360-0130) or mail (Marketplace Appeals Center, P.O. Box 311, Pittston, PA
18640). Accommodations are provided at no cost to you.
To submit your appeal request, see “How to submit this form” on page 1 of these
instructions.
Questions
For more information, visit HealthCare.gov/small-businesses/.
Paperwork Reduction Act Disclosure Statement
According to the Paperwork Reduction Act of 1995 (PRA), no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1213. The time required to complete this information collection is estimated to
average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. **CMS Disclaimer** Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note
that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this
form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the
Marketplace Appeals Center.
Privacy and Use of Your Information
The Marketplace protects the privacy and security of information about you that you’ve provided. To view the Privacy Act Statement, go to HealthCare.gov/
individual-privacy-act-statement/. We’re authorized to collect the information on this form and any supporting documentation, including Social Security
numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111–148), as amended by the Health Care and Education Reconciliation Act of 2010
(Public Law No. 111–152), implementing regulations in 45 CFR part 155, subpart F, and the Social Security Act. For more information about the privacy and security
of your information, visit HealthCare.gov/privacy/.
Nondiscrimination
The Health Insurance Marketplace doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin,
disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you can file a complaint with the Department of
Health and Human Services, Office for Civil Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201.
SHOP Employer Eligibility Appeal Request Form (10/2018)
SHOP Employer Eligibility Appeal Request
Page 1 of 3
Form Approved
OMB No. 0938-1213
SHOP Appeal Request Form – Employer
Enter your information directly, then print and sign your completed form.
Or, print a blank form to ll in using black or dark blue ink.
SECTION 1: Employer information.
1. Name of the primary contact on your SHOP application (First name)
(Last name)
What’s the earliest effective date you chose for your group? (mm/dd/yyyy)
Business mailing address
City
(Middle name)
Apartment or suite number
State ZIP code
Primary contact’s phone number
Email address (optional)
Employer ID Number (EIN)
Your SHOP Application ID number
EMPLOYER CONTACT
This should be lled out by the person requesting the appeal. The Marketplace will correspond with this person regarding this appeal. There’s
also space for identifying a secondary contact for the employer.
Primary contact’s title
Business name
SHOP Employer Eligibility Appeal Request Form (10/2018)
SECONDARY CONTACT
(additional person who may act on your behalf regarding this appeal request)
Secondary contact’s business mailing address
City
Apartment or suite number
State ZIP code
Secondary contact’s phone number
Page 2 of 3
1. Name (First name)
(Last name)
(Middle Name)
Secondary contact’s title
Email address (optional)
SHOP Employer Eligibility Appeal Request Form (10/2018)
Page 3 of 3
SECTION 3: Signature
I’m signing this form under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best
of my knowledge. I know that I may be subject to penalties under federal law if I provide false and/or untrue information.
Date (mm/dd/yyyy)Signature
Printed name of person requesting an appeal (or authorized representative, if applicable) (First name, Middle name, Last name)
SECTION 2: Reason for this appeal.
Date of eligibility notice (mm/dd/yyyy)
Your eligibility determination notice explains if you qualify for participation in the SHOP Marketplace as an employer. You can
appeal the eligibility determination for either of these reasons:
• You weren’t eligible.
• You think that the SHOP didn’t make your eligibility determination in a timely manner.
Explain the reason for your appeal. Your explanation should include the reason you think we made a mistake. Add more pages if
needed. If you’re including documents to support your request, send us copies. Keep all original documents.
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Form Approved: Instructions to help you complete the (Centers for Medicare & Medicaid Services)

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Completed 19 July 2020

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