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

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms necessary to make changes to the plan can be obtained from the employer’s personnel office, from Our home office. If the Member needs to submit documentation to Us, the Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809 All the forms related to filing claims under this Benefit Plan can be obtained by contacting United Concordia Dental at: United Concordia Dental Customer Service P.O. Box 69441 Harrisburg, PA 17106-9441 0-000-000-0000 If the Member has any questions about any of the information in this section, the Member may speak to his Employer or call UCD. Members may be able to perform many of these functions online at xxx.xxxxxx.xxx. CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets You know when You may add additional family Members to Your policy. Please read the Schedule of Eligibility and this section as they contain important information for You. A Group Enrollment Change Form is the document that We must receive in order to enroll family Members not listed on Your original application/enrollment form. The Group Enrollment Change Form is used to add newborn children, newborn adopted children, a Spouse, or other Dependents. It is extremely important that You follow the timing rules in the Schedule of Eligibility. If You do not complete and return a required Group Enrollment Change Form to Us within the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members. Completing and returning a Group Enrollment Change Form is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible Dependents.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms necessary to make changes to the plan can be obtained from the employer’s personnel office, office or from Our home office. If the Member needs to submit documentation to Us, the Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809 All the forms related to filing claims under this Benefit Plan can be obtained by contacting United Concordia Dental at: United Concordia Dental‌ Dental Customer Service Claims P.O. Box 69441 Harrisburg, PA 17106-9441 0-000-000-0000 If the Member has any questions about any of the information in this section, the Member may speak to his Employer or call UCD. Members may be able to perform many of these functions online at xxx.xxxxxx.xxx. CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets You the Member know when You may add it is necessary for the Member to apply for coverage to enroll additional family Members members to Your policy. Please read the Schedule of Eligibility and this section as they contain important information for YouMember’s plan. A Group Enrollment Change Form is the document that We must receive in order to enroll family Members members not listed on Your the Member’s original application/enrollment form. The Group Enrollment Change Form is used to add newborn children, newborn adopted children, a Spouse, or other Dependents. It is extremely important that You follow the timing rules in the Schedule of Eligibility. If You do not complete and return a required Group Enrollment Change Form to Us within the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members. Completing and returning a Group Enrollment Change Form is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible Dependents. 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: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, PA 17106-9441 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to Claims Administrator 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form)‌‌‌ the Claim is completed and signed by the Member and the Provider. IMPORTANT NOTE: The Member must be sure to check all Claims for accuracy. This contract number (ID #) must be correct. It is important that the Member keep a copy of all bills and Claims submitted. If Blue Cross and Blue Shield of Louisiana is a secondary payor, the Member may be required to submit his Explanation of Benefits from his primary payor. IF A MEMBER HAS A QUESTION ABOUT HIS CLAIM If a Member has a question about the processing or payment of a Claim, the Member can write Us at the below address or the Member may call Claims Administrator at 0-000-000-0000. If the Member calls for information about a Claim, We can help the Member better if the Member has the information at hand--particularly his contract number, patient's name and date of service. United Concordia Dental Customer Service P.O. Box 69420 Harrisburg, PA 17106-9420 Remember, the Member must ALWAYS refer to his contract number in all correspondence and recheck it against the contract number on the Member’s ID card to be sure it is correct. GENERAL PROVISIONS – GROUP/POLICYHOLDER ONLY IN ADDITION TO THE GENERAL PROVISIONS FOR GROUP/POLICYHOLDER AND MEMBERS, THE FOLLOWING GENERAL PROVISIONS WILL ALSO APPLY TO THE GROUP/POLICYHOLDER. Due Date for Group’s Premium Payments Premiums are due and payable from Group/Policyholder in advance, prior to coverage being rendered. Premiums are due and payable beginning with the Effective Date of this Benefit Plan and on the same date each month thereafter. This is the premium due date. Premiums are owed by Group/Policyholder. Premiums may not be paid by third parties, including but not limited to Dentists, Hospitals, Pharmacies, Physicians, automobile insurance carriers, or other insurance carriers. Company will not accept premium payments by third parties unless required by law to do so. The fact that Company may have previously accepted a premium from an unrelated third party does not mean that Company will accept premiums from these parties in the future. If a premium is not paid when due, We may agree to accept a late premium. We are not required to accept a late premium. The fact that We may have previously accepted a late premium does not mean we will accept late premiums in the future. You may not rely on the fact that We may have previously accepted a late premium as indication that We will do so in the future. Premiums must be paid in US dollars. Policyholder will be assessed a twenty-five dollar ($25.00) NSF fee should its premium be paid with a check that is returned by the bank due to insufficient funds. If multiple payments are returned by the bank, Company may at its sole discretion refuse to reinstate coverage. Change in Premium Amount Premiums for this Benefit Plan may increase after the Group’s first twelve (12) months of coverage and every six (6) months thereafter, except when premiums may increase more frequently as described in the following paragraph. Except as provided in the following paragraph, We will give Group forty-five (45) days written notice of any change in premium rates. We will send notice to the Group’s latest address shown in Our records. Any increase in premium is effective on the date specified in the rate change notice. Continued payment of premium will constitute acceptance of the change.‌‌ We reserve the right to increase the premiums more often than stated above due to a change in the extent or nature of the risk that was not previously considered in the rate determination process at any time during the life of the Benefit Plan. This risk includes, but is not limited to, the right to increase the premium amount because of: (1) the addition of a newly covered person; (2) the addition of a newly covered entity; (3) a change in age or geographic location of any individual insured or policyholder;

MAKING PLAN CHANGES AND FILING CLAIMS. ‌‌‌ All of the forms necessary to make changes to the plan can be obtained from the employer’s personnel office, office or from Our home office. If the Member needs to submit documentation to Us, the Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809 All the forms related to filing claims under this Benefit Plan can be obtained by contacting United Concordia Dental at: United Concordia Dental Customer Service Dental Claims P.O. Box 69441 Harrisburg, PA 17106-9441 0-000-000-0000 If the Member has any questions about any of the information in this section, the Member may speak to his Employer or call UCD. Members may be able to perform many of these functions online at xxx.xxxxxx.xxx. CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets You know when You may add the Member knowwhen it is necessary for the Member to apply for coverage to enroll additional family Members members to Your policy. Please read the Schedule of Eligibility and this section as they contain important information for YouMember’s plan. A Group Enrollment Change Form is the document that We must receive in order to enroll family Members members not listed on Your the Member’s original application/enrollment form. The Group Enrollment Change Form is used to add newborn children, newborn adopted children, a Spouse, or other Dependents. It is extremely important that You follow the timing rules in the Schedule of Eligibility. If You do not complete and return a required Group Enrollment Change Form to Us within the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members. Completing and returning a Group Enrollment Change Form is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible Dependents. 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: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, PA 17106-9441 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to Claims Administrator 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:

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms necessary to make changes to the plan can be obtained from the employer’s personnel office, office or from Our home office. If the Member needs to submit documentation to Us, the Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809 All the forms related to filing claims under this Benefit Plan can be obtained by contacting United Concordia Dental at: United Concordia Dental‌ Dental Customer Service Claims P.O. Box 69441 Harrisburg, PA 17106-9441 0-000-000-0000 If the Member has any questions about any of the information in this section, the Member may speak to his Employer or call UCD. Members may be able to perform many of these functions online at xxx.xxxxxx.xxx. CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets You the Member know when You may add it is necessary for the Member to apply for coverage to enroll additional family Members members to Your policy. Please read the Schedule of Eligibility and this section as they contain important information for YouMember’s plan. A Group Enrollment Change Form is the document that We must receive in order to enroll family Members members not listed on Your the Member’s original application/enrollment form. The Group Enrollment Change Form is used to add newborn children, newborn adopted children, a Spouse, or other Dependents. It is extremely important that You follow the timing rules in the Schedule of Eligibility. If You do not complete and return a required Group Enrollment Change Form to Us within the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members. Completing and returning a Group Enrollment Change Form is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible Dependents. 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: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, PA 17106-9441 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to Claims Administrator 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form)‌‌‌ the Claim is completed and signed by the Member and the Provider. IMPORTANT NOTE: The Member must be sure to check all Claims for accuracy. This contract number (ID #) must be correct. It is important that the Member keep a copy of all bills and Claims submitted. If Blue Cross and Blue Shield of Louisiana is a secondary payor, the Member may be required to submit his Explanation of Benefits from his primary payor.

MAKING PLAN CHANGES AND FILING CLAIMS. All of the forms necessary to make changes to the plan mentioned in this section can be obtained from the employerEmployer’s personnel office, office or from Our the home officeoffice of Blue Cross and Blue Shield of Louisiana. If the Member needs to submit documentation to Us, the Member may forward it to Our home office at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029 or to Our street address, 0000 Xxxxx Xxxxxx, Baton Rouge, LA 70809 All the forms related to filing claims under this Benefit Plan can be obtained by contacting United Concordia Dental at: United Concordia Dental Customer Service P.O. Box 69441 Harrisburg, PA 17106-9441 0-000-000-0000 70809. If the Member has any questions about any of the information in this section, the Member may speak to his their Employer or call UCD. Members may be able to perform many of these functions online the Customer Service Department at xxx.xxxxxx.xxxthe number shown on his ID card. CHANGING FAMILY MEMBERS ON THE MEMBER’S PLAN The Schedule of Eligibility lets You the Member know when You may add it is necessary for the Member to apply for coverage to enroll additional family Members members to Your policythe Member’s plan. Please The Member should read the Schedule of Eligibility and this section as they contain important information for Youinformation. A The Group Enrollment Change Form is the document that We must receive in order to enroll family Members members not listed on Your the Member’s original application/enrollment form. The Schedule of Eligibility will tell the Member whether We require the Group 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 Member does not complete and return a required Group Enrollment Change Form to Us so We receive it within the timeframes set out in the Schedule of Eligibility, it is possible that the Member’s insurance coverage will not be expanded to include the additional family members. Completing and returning a Group Enrollment Change Form is especially important when the Member’s first Dependent becomes eligible for coverage or when the Member no longer has any eligible Dependents. If the Member has any changes in their family, the Member must file a Group 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, a Group Enrollment Change Form is used to add newborn children, newborn adopted children, a Spousespouse, or other DependentsDependents not listed on the Member’s original application for coverage. It is extremely important that You follow We should receive the timing rules Member’s completed form in Our home office within thirty (30) days of the Schedule of Eligibility. If You do not complete and return a required Group Enrollment Change Form to Us within child’s birth or placement, or the timeframes set out in the Schedule of Eligibility, it is possible that Your insurance coverage will not be expanded to include the additional family Members. Completing and returning a Group Enrollment Change Form is especially important when Your first Dependent becomes eligible for coverage or when You no longer have any eligible DependentsMember’s marriage.