Request a Quote

Thank you for considering Evolutions Healthcare Systems for your PPO needs. For your convenience the list of questions below details the information needed to provide a network quote, GEO Report, CPT Analysis, or Disruption Report. Our Account Managers are ready to assist you with your questions and requests. 

 

Standard Information

· Requestor’s name, phone, and email address

· The TPA Account Manager, phone and email address (if different)

· Plan Sponsor Name and Address

· Current plan effective date and proposed plan effective date

· Current Administrator if this is a new business opportunity

· Broker’s Name and Contact Information

· Current health care network affiliations

· Product Requested:


Additional Information Required for: 

GEO Report

· Employee census information including sex, birth date, and employee zip codes (Please submit in Microsoft Excel)

· Access Standards (i.e. 1 Hospital within 25 miles, 1 PCP within 15 miles)

· Average number of employees on payroll each month for the past three years

CPT Analysis

· List of CPT codes to be referenced

· List of Facilities or Zip codes for analysis

· Most recent twelve months claims experience

Disruption Report

· List of 7 digit provider tax identification numbers

· List of Provider Names

· List of Provider Addresses


 

Submit Request for Proposal

Please submit your RFP and census information electronically (Word or Excel) to sales@ehsppo.com.


For additional Information please contact the Sales & Marketing Department.