Agmt23 AETNA - Laserfiche WebLink

Browse Search

HHRC-EOC 02.10.2017 6 Evidence of Coverage Requests for second opinions may be made by contacting the Director, Clinical Quality Improvement at (1-800-342-8111) or in writing to 10260 Meanley Drive, San Diego, CA 92131. All requests for second opinions shall be processed and approved or denied by Plan within five (5) business days of receipt. Requests related to urgent care or crisis intervention shall be processed and approved or denied within forty-eight (48) hours of receipt. XI. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE All Enrollees identified by Group prior to the effective date of the EAP Services Agreement and all persons covered under the identified Enrollee’s health benefit plan or residing with the identified Enrollee shall be entitled to Benefits as of such effective date. Group shall be responsible for notifying Plan of any Enrollee who becomes newly eligible after the effective date of the EAP Services Agreement. Plan shall rely upon the determination by Group as to which Enrollees are eligible for Benefits under the EAP Services Agreement. Any disputes or inquiries regarding eligibility, including rights regarding renewal, reinstatement and the like, shall be referred by Plan to Group, which shall then advise Plan of its determination with respect to the matter. XII. TERMINATION OF BENEFITS Usually, your enrollment in the plan terminates when Group or Enrollee is no longer eligible for coverage under the employer’s EAP plan. In most instances, Group determines the date in which coverage will terminate. Coverage can be terminated, however, because of other circumstances as well, which are described below. A. Cancellation of Group Contract for Nonpayment of Premiums Continuing coverage under this EAP Plan is subject to the terms and conditions of Group’s EAP Services Agreement with Plan. If the EAP Services Agreement is cancelled because Group failed to pay the required premiums when due, then coverage for you and all your dependents will end 15 days after Group mails you the Notice Confirming Termination of Coverage. Plan will mail your Group a notice at least 30 days before any cancellation of coverage. This Prospective Notice of Cancellation will provide information to your Group regarding the consequences of your Group’s failure to pay the premiums due within 15 days of the date the notice was mailed. If payment is not received from Group within 15 days of the date the Prospective Notice of Cancellation is mailed, Plan will mail Group a Notice Confirming Termination of Coverage, which Group will then forward to you. This notice will provide you with the following information: 1) That Group’s EAP Services Agreement has been cancelled for non-payment of premiums; REV: 03-10-23 MI ATTY/AGR.2023.039/Aetna (EAP Services Agreement) (Page 30 of 42)