the archdiocese of new york benefits administration resource guide

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CERTIFICATION FOR DISABLED DEPENDENT CHILDREN OVER THE AGE OF NINETEEN (19) Members who are covered under the Group Health Benefit and have a covered Dependent Child(ren) over the age of 19, who is disabled, must submit a completed Statement of Dependent Eligibility Beyond Limiting Age In Plan Due To Mental Retardation or Mental or Physical Handicap form (refer to sample form on the following page). The Local Administrator should complete and sign the Employer’s Statement, before giving the form to the employee. Instruct the employee to complete the Employee Section of the form and have the dependent child’s physician complete the Physician’s Statement. Upon completion of the form the employee can make a copy for their confidential file and mail the original form to United Healthcare (address is listed on the form). United Healthcare will review the Certification and notify the member and the Employee Benefit Connections Department at the Archdiocese, if the dependent child is approved to remain as an eligible dependent on the group health benefit, and when re-certification is required. For additional information, call United Healthcare at 800.736.1264. - 13 -
STATEMENT OF DEPENDENT ELIGIBILITY BEYOND LIMITING AGE IN PLAN DUE TO MENTAL RETARDATION OR MENTAL OR PHYSICAL HANDICAP EMPLOYEE’S STATEMENT ANSWER ALL QUESTIONS BELOW. OMITTED INFORMATION WILL CAUSE DELAYS. Name (Print) First Middle Last Social Security Number Date of birth Male / / Female Present Street City State Zip Code Marital Single Widowed Phone (with area code) Address: Status: Married Divorced ( ) Dependent Information Name (Print) First Middle Last Social Security Number / / Present Street City State Zip Code Marital Single Address: Status: Married Date of birth Male Female Relationship to Employee Name and address of dependent’s current employer If not now employed, give date last employed Estimated income of dependent from all sources $_____________ monthly Percentage of support of dependent supplied by employee _______________% Is dependent permanently residing in employer’s household? Yes No If No, Explain Is dependent listed as a dependent in your last Federal Personal Income Tax Return? Yes No If No, Explain Explanations I KNOW IT IS A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR TO LEAVE OUT FACTS I KNOW ARE IMPORTANT. Signed (Employee) Date PHYSICIAN’S/SURGEON’S STATEMENT ANY FEE FOR THE COMPLETION OF THIS STATEMENT TO BE PAID BY THE EMPLOYEE. ANSWER ALL QUESTIONS BELOW. OMITTED INFORMATION WILL CAUSE DELAYS. Patient’s Name First Middle Last Patient’s Date of Birth Is this dependent presently incapable of self-sustaining employment by reason of: Mental Retardation? Physical Handicap? Mental Handicap? Other (explain) Yes No Yes No Yes No Yes No Date dependent became incapable of self-sustaining employment Diagnosis of condition causing incapacity. If mental retardation is present, give degree of retardation. Give as much detail as possible. Please give date and report of surgery, X-rays, electrocardiograms, or other special tests. Use a separate sheet of paper if necessary. Does the patient have a job? Yes No Do you know what the patient’s job is? Yes No Do you know what the duties the patient’s job requires? Yes No Has this patient been able to do full or part-time work of any Will the patient be capable of self support? kind? No Yes, From _____________ Date No Yes, From _____________ Date The patient is presently (check one) Ambulatory Bed confined House confined Hospital confined Physician’s/Surgeon’s Name (Print) Address Phone (with area code) ( ) I KNOW IT IS A CRIME TO FILL OUT THIS FORM WITH FACTS I KNOW ARE FALSE OR TO Date LEAVE OUT FACTS I KNOW ARE IMPORTANT. Signed EMPLOYER’S STATEMENT ANSWER ALL QUESTIONS BELOW. OMITTED INFORMATION WILL CAUSE DELAYS. Employee’s Name First Middle Last Certificate No. Date dependent’s coverage was originally effective If previously canceled, give date. Employer Group Branch Sub Division Title Date Signed by FOR USE BY United Healthcare Dependent eligibility will continue to Month Day Year Dependent eligibility declined. Give reason. Signature Date
Page 1 and 2: THE ARCHDIOCESE OF NEW YORK BENEFIT
Page 3 and 4: 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: ARCHDIOCESE OF NEW YORK Group Healt
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 57 and 58: Choice Plus Benefits Summary Types
Page 59 and 60: UnitedHealthcare Additional Benefit
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 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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