the archdiocese of new york benefits administration resource guide

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THE ARCHDIOCESE OF NEW YORK MISSION STATEMENT The beliefs and principles of the Catholic Faith serve as the basis for the operation of the Archdiocese of New York and its constituent members as expressed in the following mission statement. We, the Catholic People of God of the Archdiocese of New York have a mission, given by the Lord Himself, to live and proclaim His gospel message. This mission, entrusted by Jesus, calls us to be aware of the local area and the world, the spiritual and the material, the present and the future. The same gospel that challenges us is also our consolation. The same Lord who commanded, “Go therefore and make disciples of all nations,” added, “I am with you always, until the end of the world.” (Matthew 28:19-20)
THE ARCHDIOCESE OF NEW YORK BENEFITS ADMINISTRATION RESOURCE GUIDE TABLE OF CONTENTS I. Important Information: Page - Important Notice 1 - New Employee Checklist 2 - Benefits Administrator’s Resource Contacts List 3 - Rules For Member Groups Participating in the Archdiocesan Group Insurance Plan 4 - Benefits Eligibility Outline 5 - AONY Division Claim Codes 6 - Change of Contact 7 II. Administration of Group Health Benefit Plan: - HIPAA (Health Insurance Portability & Accountability): Notice of Privacy Practices 8 - AONY Authorization For Release of Information 9 - United Healthcare Authorization for Use and Disclosure of Private Health Information 10 - AONY Group Health Benefits Eligibility 11 - How to Enroll in the Group Health Benefit Plan and/or Make Changes to a Member’s Group AONY Health Benefit Coverage or Change Personal Information 12 - Certification for Disabled Dependent Children over the age nineteen (19) 13 - Certification of Disability for the Disabled Children’s Provision Form 14 III. Benefits Summaries: - Summary of Benefits: For Clergy, Religious, Seminarians & Lay Employees 15 - Summary of Benefits: For Bargaining Lay Faculty 16 - Summary of Benefits: For Medicare Supplement for Retired Lay Employees over age 65, Clergy and Religious Who have Medicare Primary Benefits (MSYRX) 17 IV. Filing for Claims: - How to File a Medical Claim (Instructions) 18 - Prescription Benefit Summary 19 - How to File a Claim for Prescription Drugs (Instructions) 20 V. When Group Health Benefit Coverage Ends…….. - Important Notice (Administration Instructions): for completing Benefit Transfer, 21 Termination and Reinstatement Transmittal Form - Benefit Transfer, Termination and Reinstatement Transmittal Form 22 - Group Health Benefits For Employees Separating From Service 23 - (Sample Letter) Notice to Member Losing Coverage 24 - AONY Notice of Group Benefit Continuance Eligibility 25 - Group Health Benefits For Employees Retiring from Service Prior to Age 65 26 - Group Health Benefits For Employees Retiring from Service at Age 65 or Later 27 - Notice of Benefit Status due to Separation from Employment 28 Revised July 2009 1
Page 1: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 5 and 6: Section I Important Information
Page 7 and 8: NEW EMPLOYEE CHECKLIST The followin
Page 9 and 10: BENEFITS ADMINISTRATOR RESOURCE CON
Page 11 and 12: VENDOR CONTACT PHONE WEBSITES POLIC
Page 13 and 14: RULES FOR MEMBER GROUPS PARTICIPATI
Page 15 and 16: 5. All clergy and religious orders
Page 17 and 18: BENEFIT ELIGIBILITY OUTLINE -5-
Page 19 and 20: BENEFITS ELIGIBILITY EFFECTIVE DATE
Page 21 and 22: DIVISION CLAIM CODES -6-
Page 23: Group 3000 - New York State Continu
Page 27 and 28: HEALTH INSURANCE PORTABILITY & ACCO
Page 29 and 30: Revised: January 1, 2006 Effective:
Page 35 and 36: ARCHDIOCESE OF NEW YORK AUTHORIZATI
Page 37 and 38: AUTHORIZATION FOR THE USE AND DISCL
Page 39 and 40: HOW TO ENROLL IN THE GROUP HEALTH B
Page 41 and 42: Annual Salary (Benefit Administrato
Page 43 and 44: ARCHDIOCESE OF NEW YORK Group Healt
Page 45 and 46: ARCHDIOCESE OF NEW YORK Group Healt
Page 47 and 48: STATEMENT OF DEPENDENT ELIGIBILITY
Page 49 and 50: THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 51 and 52: Choice Plus Benefits Summary Types
Page 53 and 54:
UnitedHealthcare Additional Benefit
Page 55 and 56:
THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 57 and 58:
Choice Plus Benefits Summary Types
Page 59 and 60:
UnitedHealthcare Additional Benefit
Page 61 and 62:
THE ARCHDIOCESE OF NEW YORK SUMMARY
Page 63 and 64:
Medicare Supplemental Plan Benefits
Page 65 and 66:
Exclusions UnitedHealthcare Except
Page 67:
HOW TO FILE A MEDICAL CLAIM There a
Page 70 and 71:
HOW TO FILE A CLAIM FOR PRESCRIPTIO
Page 72 and 73:
FILL IN FOR UP TO TWO PEOPLE WHO WI
Page 74 and 75:
STEP 2 Submission Requirements: You
Page 77 and 78:
ARCHDIOCESE OF NEW YORK BENEFITS TR
Page 79 and 80:
★ ★ REEMPLOYMENT RIGHTS YOUR RI
Page 81 and 82:
ARCHDIOCESE OF NEW YORK NOTICE OF G
Page 83 and 84:
Archdiocese of New York Group Healt
Page 87 and 88:
GROUP HEALTH BENEFITS FOR EMPLOYEES
Page 89 and 90:
ARCHDIOCESE OF NEW YORK Group Healt
Page 91 and 92:
ARCHDIOCESE OF NEW YORK Group Healt
Page 93 and 94:
___________________________________
Page 95 and 96:
Section VI Administration of Life,
Page 97 and 98:
ARCHDIOCESE OF NEW YORK Life and Ac
Page 99:
HOW TO FILE A CLAIM FOR BASIC GROUP
Page 115 and 116:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 122 and 123:
GROUP LIFE INSURANCE BENEFITS FOR E
Page 128 and 129:
Section VII Administration of Short
Page 130 and 131:
HOW TO FILE A CLAIM FOR NEW YORK ST
Page 132 and 133:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 134 and 135:
NOTICE AND PROOF OF CLAIM FOR DISAB
Page 136 and 137:
ARCHDIOCESE OF NEW YORK Benefit Pla
Page 148 and 149:
Section IX Administration of Dental
Page 150:
CIGNA Dental for Religious and Cler
Page 153 and 154:
ARCHDIOCESE OF NEW YORK CIGNA Denta
Page 155:
HOW TO FILE A DENTAL CLAIM There ar
Page 160 and 161:
DAVIS VISION CARE VISION CARE BENEF
Page 162 and 163:
ARCHDIOCESE OF NEW YORK Benefit Hig
Page 164 and 165:
HOW TO FILE A VISION CARE CLAIM (Cl
Page 166 and 167:
Section XI Administration of Volunt
Page 168 and 169:
ARCHDIOCESE OF NEW YORK SUPPLEMENTA
Page 170 and 171:
INTERNAL USE ONLY Institution Name:
Page 172 and 173:
PERSONAL HEALTH APPLICATION Thank y
Page 174 and 175:
Employee: First Name_______________
Page 176 and 177:
Employee: First Name_______________
Page 178:
IMPORTANT NOTICE The Archdiocese of
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