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2021-074B
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2021-074B
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Last modified
6/22/2021 12:13:29 PM
Creation date
6/11/2021 3:23:37 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Agreement
Approved Date
05/11/2021
Control Number
2021-074B
Agenda Item Number
12.D.1.
Entity Name
Employer Direct Healthcare, LLC
Subject
Surgeryplus Services Agreement
Addition of SurgeryPlus Benefit as Optional Benefit
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DocuSign Envelope ID: 29EAB906-1936-4BAB-83BE-97C974F00293 <br />Enrollment File Feed Requirements <br />(rev. June 2020) <br />Enrollment File feed layout <br />urgeryPlus`" <br />Usage <br />'FieldData <br />Type, <br />Desalptton - <br />IdentitV <br />Required <br />Required <br />Plan Wnsor Name <br />Plan S nsor EIN <br />Strina <br />String <br />Name of the Plan Sponsor <br />Plan §p2nsor EIN or TIN <br />Enrollee Ident" <br />Required I <br />Enrollee SSN <br />Social Security Number <br />Situational <br />Situational <br />Employee -ID <br />Enrollee Medical ID <br />String <br />String <br />Employee Identifier associated with the Enrollee <br />Enrollee Medical ID <br />Optional <br />Enrollee Supplemental -ID <br />String <br />Enrollee Supglemental ID <br />Member Idents <br />Re uired <br />Member SSN <br />String <br />Social Securi ' Number <br />Required I <br />Enrollee Indicator <br />String <br />Status of the Enrollee <br />R 'uired <br />O tional IMember3upplemental <br />Member Relationshf Code <br />ID <br />String Code Indicating the relationship between two individuals or entities <br />Strin2 Member Sup' lemental ID <br />Member Eli Ibili <br />Required I <br />Medical Coverage Status Code <br />Strini <br />Current Benefits Status <br />Re uired <br />Medical Cove a Effective Date <br />Date <br />Coverage Effective/Start Date <br />O tional Medical Covera a Termination_ Date <br />Situational COBRA_COC Event Date <br />Date Covera eTermination/EndDate <br />Date COBRA continuation of coverage Event date <br />_ <br />-2- <br />i <br />i <br />_� R <br />
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