Home // IT Change Request IT Change Request IT Change Request Requestor Name(Required) First Last Email(Required) Date Submitted(Required) MM slash DD slash YYYY Request Title(Required) Brief Summary of RequestType of Request(Required) Change Request Rate Factor Change OpenL Adjudication Change Department (Component)(Required) Account/Customer Billing Claims - Dental Claims - Non-Dental Commissions Call Center Doc-Gen Employer Portal (EIS) Employee Portal (EIS) Provider Portal Other Portals Enrollment Integration Policy Rating Reporting Sales Sales - Support Underwriting Market Development Other Department - OtherIf you selected "Other," please explain: ProductsSelect if request is related to specific product/s Dental Vision STD LTD PFL Life Accident STAT EAP Other Products - OtherIf you selected "Other," please explain: Must Have By DateIf Business must have this request by a date MM slash DD slash YYYY Reason For Must Have By DateIf Must have Date provided, please provide context supporting why request is needed by dateNice To Have By DateIf Business would like to have by a date, but not a must have MM slash DD slash YYYY Priority(Required) Critical High Medium Low Critical-Severe impact to Customers, Financial Impact to the organization, Regulatory Request, Critical Function/Process Identified as missing High- Moderate Production Issue (w/ manual work being created), Implementation of new Products/Services, Expansion of Existing Products & Services, Number of FTEs outweighs Cost to develop change/fix, Significant Customer Facing Impact Medium - Complaints received, Minimal Production Issue (w/ work around) w/ cost is equal to FTEs being used, Minor Automation improvement Low- Production issue (little to no impact), Nice to HaveDid You Select Critical Or High?Provide details about reason for Urgency. Define impact to the organization below. If SLAs are impacted, please include those.System(Required) ROS Application Fineos Employer/Employee Portal EIS Employer/Employee Portal Provider Portal Other Portals Salesforce Other System - OtherIf you selected "Other," please explain: Need By Timing(Required)Preferred period of time for delivery of request 4th Quarter 2021 1st Quarter 2022 2nd Quarter 2022 3rd Quarter 2022 4th Quarter 2022 1st Quarter 2023 2nd Quarter 2023 3rd Quarter 2023 4th Quarter 2023 Summary Of Request(Required)Summary of the change being requestedRequirement Details(Required)Provide requirement details for this request. Also think about and provide details if there are any Policy, Rating, UI, Claims, DocGen, ETC types of impacts. Use Case ExamplesWhen applicable, provide a few Use cases for this requestRelated Tickets Was a ticket previously opened for a bug, or is this related to a New Feature Ticket?Does A Workaround Exist?(Required)N/AYesNoWorkaround CommentsProvide brief description of work around, time and effort, etc.AttachmentsMax. file size: 50 MB.
