2012-038 Human Resources - Delta Dental Claims & Administrative fees

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Your Delta Dental coverage may automatically terminate: • When your employer or organization advises Delta Dental to terminate your coverage. • On the first day of the month for which your employer or organization has failed to pay Delta Dental. Delta Dental will not continue eligibility for any person covered under this program beyond the eligibility ternunation date requested by your employer or organization. A person whose eligibility is terminated may not continue group coverage under this Contract, except as required by the continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) or comparable, non-preempted state law. XI. Continuation of Coveraqe If your employer or organization is required to comply with provisions under COBRA and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and your coverage would otherwise end, you and/or your covered Eligible Dependents have the right under certain circumstances to continue coverage in the medical and dental plans sponsored by your employer or organization, at your expense, beyond the time coverage would normally end. When is Plan Continuation Coverage Available? Continuation coverage is available if your coverage or a covered Eligible Dependent's coverage would otherwise end because: l. Your employment ends for any reason other than your gross misconduct; 2. Your hours of work are reduced so that you are no longer a full-time employee; 3. You are divorced or legally separated; 4. You die; 5. Your Child is no longer eligible to be a covered Eligible Dependent (for example, because he or she turns 19); 6. You become enrolled in Medicare (if applicable); or 7. You are called to active duty in the anned forces of the United States. If you believe you are entitled to continuation coverage, you should contact your employer or organization to receive the appropriate docuxnentation required under the Employee Retirement Income Security Act of 1974 (ERISA). XII. General Conditions Chanae of Status You must notify Delta Dental, through your employer or organization, of any event that changes the status of an Eligible Dependent. Events that can affect the status of an Eligible Dependent include, but are not lixnited to, marriage, birth, death, divorce, and entrance into military service. In no event will retroactive updates to eligibility be accepted for an effective date more tha.n 90 days prior to receipt of the update by Delta Dental. Notwithstanding the foregoing, when no additional premium is required, a newborn child will be covered from the moment of birth, and a foster child or adopted child will be covered from the date of placement in the home, without regard to the timeliness of the update to eligibility. AssiQnment Services and/or benefit payments to Eligible Persons are for the personal benefit of those people and cannot be transferred or assigned, other than to the extent necessary to allow direct payments to Participating Dentists. . Obtaining and Releasing Information While you are covered by Delta Dental, you agree to provide Delta Dental with any information it needs to process your claims and administer your benefits. This includes allowing Delta Dental to have access to your dental records. Late Claims Submission Delta Dental will make no payment for services if a claim for those services has not been received by Delta Dental within one year following the date the services were completed. Failure to submit a claim within the time required does not invalidate or reduce any claim however, if it was not reasonably possible for the. Form No. 1752-NC 16 NCPPOpIus-A 01 /2012