BlueCross BlueShield of South Carolina

Group Attestation Form

August 25, 2010

We recently told you about an attestation form we are requiring all groups to complete. The purpose of this form is to verify a group’s current contribution level and contribution level on March 23, 2010.

Certain reductions to a group’s contribution level could cause the group to lose grandfathered status. Groups are required to return the completed form 30 days prior to renewal. Failure to do so will cause:

• Loss of grandfathered status
• Addition of mandated preventive benefits and possible rate increase
• Implementation of new appeals process
• Changes to reimbursement for emergency services in an out-of-network hospital’s emergency room

You can help your groups by reminding them to complete the form and fax it to us at 803-264-0143. We may contact you for assistance if a group does not return the form in a timely manner.

We will continue to check contribution levels on an annual basis. View the attestation form.

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