Each self-funded group health plan that elects to participate in the Balance Billing Protection Act must complete and submit this form and attestation to our office for each health plan offered by the sponsor with a unique Group Identification Number.

Note: The information you submit will appear on our website. 

  • Begin
  • Plan information
  • Third-party administrator information
  • Agreement
  • Complete
Are you a third-party administrator of a self-funded health plan? *