Change Request

Requestor Email(Required)

Date Submitted(Required)

Request Title(Required)

Must Have By Date

If Business must have this request by a date

Reason For Must Have By Date

If Must have Date provided, please provide context supporting why request is needed by that date

Nice To Have By Date

If Business would like to have by a date, but not a must-have.

Priority(Required)

Did you select Critical or High? Please explain.

SME's to be included in Requirement Gathering Sessions:

Form Directions: This form will ask you to outline which work stream the IT Change request will effect. If you answer "Yes" to the first work stream question, it will ask a series of related follow-up questions. You will be able to attach files (such as UI mockups) at the end of the form.

CUSTOMER WORK STREAM

Customer UI System Screens Details

Please provide UI mockup, business UI rules, and roles/privileges

System Screens Portal and Impact

Please name the portal and impact on the UI

POLICY Work Stream

Policy System Screens Additional Info

Please provide UI mockup, Business UI rules, Roles/privileges

POLICY Integration Ticket Number

Refer to Integration Appendix list located in Product Owners Teams page. Note the associated ticket number here:

Migrated Policies Details

Please provide additional details

BILLING Work Stream

UI System Screens Additional Info

Please provide the UI mockup, Business UI rules, and roles/privileges

Billing Impact Portals

Please name the portal this will impact

Impact Migrated Billing Account Details

Please provide more details on the impact on migrated billing accounts

COMMISSION Work Stream

Migrated commissions Details

Please provide more details on the impact on migrated commissions.

CLAIMS NON-DENTAL Work Stream

Impact on Claims Non-Dental UI Details

Please provide the UI mockup, Business UI rules, and Roles/privileges

Impact on Migrated Claims Details

Please provide the UI mockup, Business UI rules, Roles/privileges

CLAIM DENTAL Work Stream

Claims Dental Migrated Claims Details

Please provide more details on the impact on Migrated claims.

DOCGEN Work Stream

What Domain is this document applicable too?

Example: Policy, Billing, Claims, Etc.

Existing Document Name

Please provide the existing document as an attachment at the end of the form.

INTEGRATION Work Stream

Domain to which this Integration is applicable to:

Example: Policy, Billing, Claims, etc.

If yes (to the previous question), identify Integration name:

Refer to Integration Appendix list located in Product Owners Teams page and note associated ticket number here:

ADMIN AGENCY Work Stream

The following questions are related to your request overall:

Requirement Details: Any specific functional requirements like response timing, the volume of data that needs to be handled, security (like HIPAA), etc.?

Backward Compatibility: Should existing Prod data be modified and/or does any Prod data exist that would be affected by new changes?

Use Case Examples

When applicable, provide a few use cases for this request

Related Tickets

Was a ticket previously opened for a bug, or is this related to a New Feature Ticket?

Workaround Comments

Provide brief description of work around, time and effort, etc.

Attachments

Max. file size: 50 MB.

Please include any attachments necessary as part of your submission.

IT Change Request