Peia Form PDF Details

Ensuring accurate and up-to-date insurance records is crucial for the effective management of claims and benefits, which is where the Public Employees Insurance Agency (PEIA) Preferred Provider Benefit (PPB) Plan Coordination of Benefits Form plays a vital role. As an essential document required by the PEIA, this form must be completed annually by policyholders to prevent delays in the processing of future claims. The form collects detailed information about the policyholder, including name, ID number, address, and the dependents covered under the plan. Additionally, it inquires about any other existing insurance coverages for the policyholder and their dependents, such as medical, prescription drug, dental, vision, and hospital insurance, asking for specifics like the type of coverage, the insurance provider's details, and the effective date of the other insurance. Particularly notable is the form's request for information regarding the coordination of benefits—whether the other insurance plan uses the gender rule or the birthday rule, which helps determine the order of benefit payments. Policyholders are also asked to mention if any of the additional insurances have terminated. This comprehensive approach ensures that the PEIA has all necessary information to coordinate benefits effectively and maintain an efficient claims process. The prompt return of this questionnaire, within 30 days as requested, is emphasized to avoid any potential hitches in claims submissions, underscoring the form's importance in keeping the insurance records current and accurate.

QuestionAnswer
Form NamePeia Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesppb plan form, peia form online, peia form, blank sudoku form print

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PEIA PPB Plan

Coordination Of Benefits Form

In order to keep our records current, it is a PEIA requirement that this questionnaire be completed every 12 months. Please return this questionnaire within 30 days to prevent delays in future claim submissions.

Policyholder Name___________________________________________________

ID Number_________________________________________________________

Address____________________________________________________________

Dependents Covered__________________________________________________

1.Spouse’s Name _______________________________ Date of Birth _________________

2.Do you or any of your dependents have other insurance?

Yes No if yes: Single Family

Type of Coverage

Medical Rx Drug Dental Vision Hospital

3.Employee’s Name ____________________________________________________________

4.Please provide the name, address, and effective date of the other insurance

______________________________________________________________________________

if Medicare, please advise and give effective date _____________________________________

5.Does the other insurance plan use the gender rule or the birthday rule for coordination of benefits? Gender Birthday

6.If the other insurance has terminated, pleasE provide the termination date:_________________

Employee Signature ____________________________________ Date____________________

Day Phone _________________________

Please return this completed letter within 30 days for prompt handling. If related claims are received requiring this same information, you will not receive additional requestS.

Mail To:

HealthSmart

P O BOX 3262

CHARLESTON, WV 25332-3262

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