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Preliminary paperwork needed to

begin the underwriting process with CNY Health!  

Your time is valuable, as is ours, if you would provide the information indicated below, 

your enrollment process can be speeded up!  

Excellus Health Plan- Inc. Underwriting Requirements for Member Group Enrollment

1. Copy of most recent NYS-45-ATT with attachments. Notations must include: terminated           employees, employees working less than the minimum required hours; seasonal or temporary employees; union employees; full time employees; employees not eligible due to employer probation requirements.
2. For New Employer Group Applicants - Please provide a copy of the most recent paid bill from the previous group health carrier  
3. Proof of Business and other documentation.

*     If self-employed, a copy of the most recent filed Schedule C or F from their federal tax returns and a copy of the DBA certificate. 

*    If partnership, a copy of the most recent form 1065 (partnership), 1065K-l for each insured partner and a copy of the partnership certificate.  
*    If corporation, a copy of the most recent 1120C, 1120E, 1120S or 990 and a copy of the certificate of incorporation. Also, a copy of federal 941 quarterly report, a document which names the principals and a copy of the initial federal form SS4. 
*    If a business has been in operation less than one year, copies of estimated tax filings are required.  

  Note:     Excellus Health Plan, Inc. uses a minimum income guideline of $25,000 annual gross revenue to qualify as a bona fide employer group. Any presently enrolled or applying employer group below that threshold of income will be asked for additional information to support their status as a bona fide employer group. In addition, Excellus Health Plan, Inc. reserves the right to request additional information it feels is necessary from any employer group to support the group's claim to be a bona fide employer group.  

Subsequent to acceptance by Excellus Blue Cross/ Blue Shield 

the following items will be needed.

Subscriber Information Requirements - to be submitted with enrollment request

1. Group Member Applications 

Employees who do not enroll with Excellus Health Plan, Inc. must complete a Waiver of Coverage Form.  

2. Student Verification Form 

For groups with student coverage. Include verification from the college the student enrolled in. (if applicable)  
3. Copy of Medicare Part A and Part B and completed Medicare Secondary Payor form 

For groups with Medicare Supplemental Benefits each Medicare primary individual must Complete an application in their own social security number and submit copies of evidence of Medicare Part A& Part B coverage. 
4. Verification of Current Carrier Health Benefit Coverage

A copy of the most recent bill from the prior carrier or other acceptable proof of prior coverage allowed by HIP AA to establish pre-existing condition waiting periods.

If you have questions as to the reason or necessity for any of the requirements listed all you have to do is CALL our office at 888-457-5189 from out of the Central New York area or 457-5189 locally!