IMPORTANT REMINDERS
Enrollment
Failure to report enrollment changes could result in overpayment or denial of benefits. You will be required to
reimburse the full amount of any benefit overpayment. Refer to Section II - Eligibility and Enrollment for details.
You must keep your enrollment information updated. It is important that you notify the SSMC Human
Resources Department immediately for the following:
·
Change in marital status
·
Birth of a child or addition of a child
·
Address change
·
Student status of child age 19 or older
·
Enrolled disabled child approaching age 19
·
Marriage of your Dependent child
·
Any family member death
·
Other group health plan information, including effective dates of coverage and name and address of the
other group health plan(s)
·
If you or your Dependent become eligible for Medicare due to disability, age or End Stage Renal
Disease
COBRA Continuation of Coverage
Written notice of most qualifying events must be sent to the SSMC Human Resources Department within 60
days following the event. If written notice is not given within 60 days, continuation of coverage under COBRA
will not be available. Refer to Section II - Eligibility and Enrollment under Continuing Coverage under
COBRA for details.
Benefits Management Program
Inpatient admissions to Hospitals or other facilities, home health care, and certain medical procedures may
require a mandatory phone call before services are rendered. Failure to follow phone call requirements could
result in reduced Plan benefits. Refer to Section III - Benefits Management Program for details.
Please Note
All claims are subject to a review to decide whether services are covered according to Plan limitations. A
second opinion consultation does not guarantee benefits. You must comply with requests for additional medical
documentation as deemed necessary by the Claims Administrator to evaluate a claim for benefits. Failure to
submit requested documentation or information or to provide a signed release for pertinent medical records
could result in denial of benefits. The Claims Administrator confidentially maintains all medical documents in
accordance with applicable New York State and federal laws. Treatment decisions are independent from
payment decisions. The patient's Physician is responsible for determining whether treatment should be
rendered despite whether the charges are totally or partially included in, or excluded from, coverage under the
Plan.
