Agency Schedule Detail

Authorization Number : 855-1007

Agency Series No. : SELF02

Status : Active

Agency Web Link :

Agency : BWC

Confidential Description : Employer’s name, address, phone number, federal tax identification number and policy number.

Division : BWCRKAD

Vital Description :

Section : BWCRKADSELF

Record Title : Qualified Health Plan Application

Revision : 1

Record Description : The Qualified Health Plan (QHP) application includes the Self Insured (SI) employer’s information to plan for the medical management of it’s claims. The information in the QHP application includes written information detailing the QHP contract information, organization, health care provider network, medical case and utilization management.

Retention Period	Retention Justification	Media Code	Method of Disposal
Retain until the file is cancelled or files bankruptcy, then retain for 17 years, and then destroy.	Possible reference after five years to verify company’s stated plan for medical management.	Electronic	Delete
Retain until the file is cancelled or files bankruptcy, retain for 17 years, and then destroy. If scanned, verify the scanned image is readable, and then destroy.	Possible reference after five years to verify company’s stated plan for medical management.	Paper	Shred

Approvals

Status	Name	Title	Date
Approved	Kevin Gartrell	Records Coordinator	3/23/2016 8:37:00 AM
Approved	Melissa Roach	Records Officer	3/24/2016 10:36:00 AM
Approved	Bunnie Jones	Record Administrator	4/13/2016 9:08:00 AM
Approved	Martin Meeks	State Auditor	4/14/2016 1:48:00 PM
Approved	Fred Previts	State Archivist	4/20/2016 9:12:00 AM

Notes

Date	Reason	User