full-time student dependent certification - United Concordia

FULL-TIME STUDENT DEPENDENT CERTIFICATION
1. Name of Employee/Retiree 2. Employee/Retiree Soc. Sec. No.
3. Name of Dependent 4. Dependent's Birth Date
5. Relationship to Employee/Retiree
6. Dependent is: Single Married Divorced Separated
7. Dependent is under 25 years of age and meets the insurance program's definition of dependent children? Yes No
8. Is Dependent employed? Yes No
8a. If Yes, Full-Time Part-Time School Vacation Period Only Other_______________________________________________
9. Was Dependent covered under your present employer's insurance plan immediately prior to the Dependent Deletion Age?
Yes No
10. Is Dependent covered under any other group medical insurance or pre-payment program? Yes No
If YES, identify the other medical insurance program:
11. Full name and address of school in which Dependent is enrolled:
12. Indicate type of school:
a. High school or vocational school supported or operated by state, local or Federal government;
b. State university, college, or community college;
c. Licensed private school, college or university;
d. Licensed technical school, nurses' training school, beautician school, automotive school, or similar training school.
e. Other (please define below):
The following types of schools or courses are illustrative of those that are not acceptable for this certification:
a. Part-time courses;
b. Certain specialized course; e.g. adult education courses;
c. Schools that do not provide an entire course progression;
d. Any correspondence school; or
e. Voluntary co-op training, whether or not school sponsored, for which no credit hours are earned.
13. Dates of school term at time of claim: From to
(Month-Day-Year)
(Month-Day-Year)
14. Expected dates of: (a) Course Completion (b) Graduation
(Month-Day-Year)
(Month-Day -Year)
======================================================================================================
I certify that the above listed dependent qualifies as a full-time student under the provisions of my employer's medical
insurance program and the above information is correct to the best of my knowledge and authorize my employer to deduct
the amount of any overpayments which may occur in connection with the payment of claims for which the above identified
dependent was not eligible as he/she did not qualify as a full time student. I also authorize the release of any information
requested with respect to this certification.
(Employee/Retiree Signature)
(Date)
I certify that I am a full-time student at the above named school and authorize the school to release any information
necessary to confirm my full-time attendance at the school for the purpose of establishing my student status.
Form # IA-200 rev. 7/05
(Dependent's Signature)
(Date)

INSTRUCTIONS FOR USS STUDENT CERTIFICATION FORM
Please complete all necessary information on the Full-Time Student Dependent Certification form including signing and dating the form in the
spaces provided. Please note that the form requires the signatures of both the employee/retiree and the student.
Company Blue Cross/Blue Shield Medical Program:
• A student’s eligibility for coverage is usually determined at the time a claim for benefits is received by Highmark Blue Cross/Blue Shield.
When a claim is filed for a potential student dependent and a current Full-Time Student Dependent Certification form is not on file, a Full-
Time Student Dependent Certification form is mailed to your home. The claim is held for 30 days pending the receipt of the completed
form.
• Your child’s “full-time student” status will be certified from January through September and/or from September through January.
However, you will not receive another mailing when the certification period has expired.
• You will need to:
- Proactively request, complete and return a completed Full-Time Student Dependent Certification form prior to each of the two periods
described above, or
- Re-certify your child once it’s apparent that their claims are being denied for lack of coverage (Highmark will hold the claim and send
you a blank Full-Time Student Dependent Certification form. If the form is not returned within thirty (30) days, you will be notified
that the claim has been denied. The claim will be reprocessed for payment only upon receipt of the properly completed Full-Time
Student Dependent Certification form.), or
- Pre-certify your student dependent before any claim is filed by sending Highmark a completed form each January and September.
• When a dependent of yours is no longer a full-time student, you must call Highmark at 1-800-245-6642.
For a medical claim return Full-Time Student Dependent Certification form to:
Highmark BCBS
USS Dedicated Unit
120 Fifth Avenue
Suite P3503
Pittsburgh, PA 15222
Prescription Drug Program:
• Certification of your student dependent is required before prescription drug benefits are paid.
• If the form is not returned within thirty (30) days, you will be notified that the claim has been denied. The claim will be reprocessed for
payment only upon receipt of the properly completed Full-Time Student Dependent Certification form.
• When a dependent of yours is no longer a full-time student, you must call Medco Health at 1-800-662-8269.
For a prescription claim return Full-Time Student Dependent Certification form to:
Medco Health Solutions of North Versailles, L.L.C.
Attn: Eligibility Department
1810 Lincoln Highway
North Versailles, PA 15137
Fax Number: 412-829-3245
Dental Benefits Program:
Dependent Certification is a service that United Concordia provides to its members. Prior to when your dependent child attains the limiting age
of coverage, United Concordia will send you a Dependent Certification Form to determine if your child is eligible for student dependent
status.
The Dependent Certification Form you receive must be returned within thirty (30) days in order to ensure timely processing. Completed forms
should be sent to: Dependent Certification, United Concordia Companies, P.O. Box 69417, Harrisburg, PA 17106-9417.
Form # IA-200 rev. 7/05