The Methodist Hospital System Sample Initial Letter.pdf - ConSova

Month Day, YearSample – Dependent VerificationInitial LetterDear John Smith:Dependent Eligibility VerificationTo help control rising medical plan costs and to ensure that all dependents meet medical planeligibility requirements, The Methodist Hospital System has retained the services of ConSovaCorporation to review and verify eligibility for dependents in the Methodist medical plans.Dependent(s) you have included on The Methodist Hospital System-sponsored medical plans are listedbelow:Dependent Name Relationship Year of BirthMichelle Smith Spouse 1956Jane Smith Child 1990Your Action Items Review your list of dependents above and the detailed explanation of the documentation you willneed to provide to verify eligibility for dependent(s) on the following pages.Complete and sign the enclosed Dependent Verification Form. If any of your dependents listed aboveare no longer eligible for medical or dental coverage, please provide their names and the reason forineligibility on this form. Coverage for ineligible dependents will end as soon as administrativelypossible.Upload documentation by logging into www.consova.com/methodisthospital or maildocumentation in the enclosed postage-paid envelope with a postmark on or before Month Day,Year. You will need your PIN number to log in to the website; your PIN number is located at thebottom left hand corner of this letter.Please note: This is not a passive verification process. Non-response or incomplete documentation willresult in the termination of insurance coverage for your dependents. Once your submitted documentationhas been reviewed, ConSova will mail a letter to you regarding the updated status and if any additionalinformation is required.If you have any questions about this process or need assistance, please call ConSova’s DependentEligibility Verification Assistance Center at (866) 964-1979 Monday through Friday, 9:00 a.m. – 5:00p.m. Central Time. Please do not contact your Methodist HR Representative. The Methodist HospitalSystem will not review any documentation for the verification process. All documents must be provided toConSova for review.Thank you for your cooperation during this important initiative.Sincerely,ConSova CorporationCaution: Form contains personalized encoded information. Do not share with others.

Dependent Verification FormPlease mail this completed and signed form and the requested verification documentation, in theenclosed postage-paid envelope by Month Day, Year to ensure that coverage continues for youreligible dependents.Please check the appropriate box: I have enclosed the requested documentation to verify the eligibility of my dependent(s). I have an ineligible dependent(s) and have noted the reason below. I understand that theircoverage will end as soon as administratively possible.Ineligible Dependent(s)If any of your dependent(s) are no longer eligible for medical or dental coverage, please providehis/her name(s) and the reason for ineligibility below. Coverage for ineligible dependents will endas soon as administratively possible.Ineligible Dependent NameIneligibility ReasonSignature of Employee:Date:By signing above, I certify and warrant to The Methodist Hospital System that all information on this Dependent VerificationForm is true, correct and current as of the date signed. I further understand that if I knowingly submit false information Imay be subject to disciplinary action up to and including termination of employment. I authorize The Methodist HospitalSystem and ConSova Corporation to contact any institution or organization to verify any and all documents provided foreligibility verification.Please mail this completed and signed form along with the requestedverification documentation.Caution: Form contains personalized encoded information. Do not share with others.

Dependent RelationshipSpouseYour legally married spouse orcommon law spouse of theopposite sex(legally separated or divorcedspouses are not eligible forcoverage)Dependent Documentation RequestWhat You Need to Submit to ConSovaDocuments RequiredCopy of marriage certificate or Declaration or Informal MarriageANDA copy of your 2012 tax return transcript (front page only); please blackout the first five digits of your SSN and all financial information. You canobtain your tax return transcript from the IRS by mail, by going online tohttps://sa2.www4.irs.gov/irfof-tra/start.do, or by calling 1-800-908-9946. Note: if your spouse files married separately, head of household orsingle, you will also need to submit their 2012 tax return transcript (frontpage only). Please black out any financial information and social securitynumbers. We only need the last 4 digits of the employee's SSN.* The enclosed Benefit Verification and Information Release AuthorizationFormChild under age 26• Your natural child, legallyadopted child, or child inthe process of beingadopted;• Stepchild;• Your unmarried grandchild,whose parent is alsocovered on the medicalplan, and the grandchildlives with you and is adependent for taxpurposes;• An unmarried child underage 18 for whom you, theemployee, are the courtappointed legal guardian,and the child lives with youand is a dependent for taxpurposes; or• A child who is the subjectof a Qualified Medical ChildSupport Order (QMCSO)issued to you.Note: if you have moved since you filed your tax return, please contactthe IRS at 1-800-829-1040 to order your tax return transcript.A copy of the following documents (varies by the relationship of the childto the Employee):• Natural child or legally adopted child: State or county issued birthcertificate showing employee’s name or signed court order• Stepchild: State or county issued birth certificate showing parents’names, copy of your Marriage Certificate, and copy of your joint 2012federal tax return transcript (front page only).• Grandchild whose parent is also enrolled on the medical plan:State or county issued birth certificate and tax return transcript fromthe most recent tax season claiming this child as a dependent• Child whom you have legal guardianship who is under the age18: Signed Court Order and 2012 tax return transcript claiming thechild as a dependent. Please be sure to leave the last four digits of thedependent’s SSN visible.• Child who is the subject of a Qualified Medical Child SupportOrder: Signed Court OrderIf unable to provide any of the documents requested, the employee will need to contact ConSova for alternative documents ifapplicable.Don’t Forget! Your response is required by Month Day, Year.Would you like to receive ConSova communications electronically? Simply log into ConSova’s website atwww.consova.com/methodisthospital and select ConSova’s “Going Green” option at the top of the page tolearn more about our paperless option.Caution: Form contains personalized encoded information. Do not share with others.