CMS Submission Request

Please complete a separate form for each item/material being submitted.

"*" indicates required fields

Agent or Agency Name*

First Last

Material Type*

Please select the type of material being submitted for review.

Material

Max. file size: 32 MB.

Please upload a copy of your material for review. For websites, please upload a Word or PDF document with the URL included. Please note that Scripts and Websites must go through the full carrier and CMS approval process which can take up to 60 days. All other materials will be submitted via the 5-day file and use process.

Material Description*

Please provide a brief description of the material (i.e. Generic mailer).

Standard Material ID (SMID)*

All materials being submitted for HPMS filing must include an SMID. SMIDs should be included on the material (usually found in the bottom left hand corner). SMIDs can be up to 50 characters and must begin with “MULTIPLAN_”, contain a combination of letters and numbers unique to the material, and end with “_M.”(Example: MULTIPLAN_1234abcd_M or MULTIPLAN_5678wxyz_2022 for websites.) To ensure numbers are unique in HPMS, it is recommended including your agency name in the ID.

Carriers

Aetna

BCBS (IL, MN, MT, NM, OK, TX)

Humana

Wellcare

Anthem

Cigna

UnitedHealthcare

Other

Please select ALL carriers you will be using this material to generate leads for. Please note, we can only file for carriers you have through GoldenCare.

Email*

Please provide the email address you would like HPMS filing updates sent to.

Phone*

For Assistance: 866-862-2325

CMS Submission Request

866-862-2325

For Assistance

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