Health Risk Assessment (HRA) Form (English)

Health Risk Assessment (HRA) Form (Spanish)

CA MAPD HRA Incentive Program Guidelines 

CA FIDE-SNP HRA Incentive Program Guidelines 

TX/AZ/NV/NM HRA Incentive Program Guidelines 

• Obtain a Scope of Appointment prior to presenting plan
• Submit the Electronic Enrollment to SCAN immediately while with the client
• Provide the beneficiary with the following:
  • Receipt of Application (found in the Sales Kit) and enter the Confirmation Number generated by SCANCubed
  • Sales Kit which contains:
    Summary of Benefits
    Formulary
    Multi-language insert
    Enrollment Forms
    Coordination of Services Form
  • Plan Star Rating document must always be presented

• Obtain a Scope of Appointment prior to presenting plan
• Provide the beneficiary with the following:
  • Receipt of Application
  • Sales Kit which contains:
    Summary of Benefits
    Formulary
    Multi-language insert
    Enrollment Forms
    Coordination of Services Form
  • Plan Star Rating document
• Deliver the Enrollment Forms or fax to SCAN within 48 hours or send via Fed Ex

1) Obtain a Scope of Appointment prior to presenting plan.

2) Complete a Telephonic Confirmation - a phone interview that agents and applicants must complete together for SCAN to process their enrollment application.

The Telephonic Confirmation acts as an electronic signature and verifies the prospective members’ intent to enroll with SCAN Health Plan.

During the phone verification, the agent will receive a confirmation number that must be included on the signature line of the paper application and on the SOA in lieu of a “wet” signature before submitting.

SCAN’s Telephonic Confirmation Representatives are available to take calls Monday–Friday from 7:00 am–6:00 pm (PST). Note: All calls are recorded. Call 855-662-7226 to get started.

3) Provide the beneficiary with the following:

• Receipt of Application (found in the Sales Kit) and enter the Confirmation Number generated by SCANCubed
• Sales Kit, which contains:
    - Summary of Benefits
    - Formulary
    - Multi-language insert
    - Enrollment Forms
    - Coordination of Services Form

Plan Star Rating document must always be presented

• Must be keyed in within 24 hours of the time the paper application is signed by the beneficiary.
• If the enrollment is not entered into the SCANCubed enrollment portal within 24 hours, you must provide SCAN with the paper Enrollment Application within 48 hours of the beneficiary’s signature on the Enrollment Application.

• Store the Scope of Appointment Form and proof of permission to contact for a period of 10 years in a secure location and supply to SCAN upon request for audit purposes
• If you decide NOT to continue contracting with SCAN, your up-line agency is responsible for ensuring the documentation is stored and retrievable for 10 years
• Documentation can be faxed to: (866) 951-6318 or (562) 989-5243
• Or they can be sent via Fed Ex to:
  SCAN Enrollment, Reconciliation and Premium Billing Department
  3800 Kilroy Airport Way, Suite 100
  Long Beach, CA 90801