Common use of MAKING PLAN CHANGES AND FILING CLAIMS Clause in Contracts

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant needs to submit documentation, the Plan Participant may forward it to Blue Cross and Blue Shield of Louisiana at P.O. Box 98029, Baton Rouge, LA 70898-9029, or to 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant has any questions about any of the information in this section, the Plan Participant may speak to his Employer or call the Claims Administrator’s customer service department at the telephone number shown on his ID card. Adding or Changing the Plan Participant’s Family Members on the Plan The Schedule of Eligibility lets the Plan Participant know when it is necessary to enroll additional family members for Dependent coverage under the Plan. Please read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participant. Group may require the Employee to use the Employee Enrollment Change Form to enroll family members not listed on the Employee’s original enrollment form. If the Plan Participant does not complete and return a required Employee Enrollment Change Form to the Plan so the Claims Administrator receives it within the timeframes set out in the Schedule of Eligibility, it is possible that the Employee’s health benefits coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment Change Form is especially important when the Employee’s first Dependent becomes eligible for coverage or when the Employee no longer has any eligible Dependents. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment Change Form is used to add newborn children, newborn adopted children, a spouse, or other Dependents not listed on the Employee’s original enrollment form. The Plan should receive the Employee’s completed form within thirty (30) days of the child’s birth or placement, or the Employee’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana at P.O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on listedon the EmployeeMember’s original originalapplication/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance contract, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s policy. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible DependentseligibleDependents. If the Member has any changes in their family, the Member must file an Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana at P.O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on the EmployeeMember’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance contract, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s policy. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file an Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana at P.O. P. O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his the ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on the EmployeeMember’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance plan, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s policy. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file an Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. ‌‌‌ All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana at P.O. P. O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his the ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on the EmployeeMember’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance plan, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s plan. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file an Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana at P.O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on the EmployeeMember’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance plan, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s policy. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file an Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms mentioned in this section can be obtained from the Employer’s personnel office or Our home office, from one of the Claims Administrator’s local service offices, or from the home office of Blue Cross and Blue Shield of Louisiana. If the Plan Participant Member needs to submit documentationdocumentation to Us, the Plan Participant Member may forward it to Our home offic e at: Blue Cross and Blue Shield of Louisiana at P.O. Box 98029, 98029 Baton Rouge, LA 7089898029-9029, 9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809. If the Plan Participant Member has any questions about any of the information in this section, the Plan Participant Member may speak to his their Employer or call the Claims Administrator’s customer service department at the telephone number shown on his ID card. Adding or Changing the Plan Participant’s Family Members on the Plan CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets the Plan Participant Member know when it is necessary for the Member to apply for coverage to enroll additional family members for Dependent coverage under to the PlanMember’s plan. Please The Member should read the Schedule of Eligibility Article and this section as they contain important information for the Plan Participantinformation. Group may require the Employee to use the The Employee Enrollment / Change Form is the document that We must receive in order to enroll family members not listed on the EmployeeMember’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Employee Enrollment / Change Form and/or the health questionnaire. Because the Member is covered under a Group insurance contract, it is extremely important that the Member follow the timing rules in the Schedule of Eligibility for making these changes to the Member’s policy. If the Plan Participant Member does not complete and return a required Employee Enrollment / Change Form to the Plan Us so the Claims Administrator receives We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the EmployeeMember’s health benefits insurance coverage will not be expanded to include the additional family members. Completing and returning an a Employee Enrollment / Change Form is especially important when the EmployeeMember’s first Dependent becomes eligible for coverage or when the Employee Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file a Employee Enrollment / Change Form. The Member may also be asked to complete the health questions for these family members. The Schedule of Eligibility explains when coverage becomes effective for new family members. Generally, an a Employee Enrollment / Change Form is used to add newborn children, newborn adopted children, a spouseSpouse, or other Dependents not listed on the EmployeeMember’s original enrollment formapplication for coverage. The Plan We should receive the EmployeeMember’s completed form in Our home office within thirty (30) days of the child’s birth or placement, or the EmployeeMember’s marriage. FILING INSURANCE CLAIMS FOR BENEFITS The Company and most Providers have entered into agreements that eliminate the need for a Member to personally file a Claim for Benefits. Participating Providers will file Claims for Members either by mail or electronically. In certain situations, the Provider may request the Member to file the Claim. If the Member’s Provider does request the Member to file directly with the Company, the following information will help the Member in correctly completing the Claim form. If You need to file a paper claim, send it to: Xxxxx Vision P.O. Box 1525 Latham, NY 12110 The Member’s Blue Cross and Blue Shield Identification Card (ID card) shows the way the name of the Subscriber (Member of the Group) appears on the Company records. (If the Member has Dependent coverage, the name(s) are recorded as the Member wrote them on the enrollment form.) The ID card also lists the Member’s Identification number (ID #). This number is the identification to the Member’s membership records and should be provided to Xxxxx Vision each time a Claim is filed. If the Subscriber completes the Claim form and this is a Group plan, remember: the Subscriber is the employee Member (if this is a group contract). If the Subscriber is the patient, the relationship is SELF. If the Subscriber’s wife or husband is the patient, the relationship is SPOUSE. To assist in promptly handling the Member’s Claims, the Member must be sure that: