full-time student dependent certification - United Concordia

INSTRUCTIONS FOR USS STUDENT CERTIFICATION FORM
Please complete all necessary information on the Full-Time Student Dependent Certification form including signing and dating the form in the
spaces provided. Please note that the form requires the signatures of both the employee/retiree and the student.
Company Blue Cross/Blue Shield Medical Program:
• A student’s eligibility for coverage is usually determined at the time a claim for benefits is received by Highmark Blue Cross/Blue Shield.
When a claim is filed for a potential student dependent and a current Full-Time Student Dependent Certification form is not on file, a Full-
Time Student Dependent Certification form is mailed to your home. The claim is held for 30 days pending the receipt of the completed
form.
• Your child’s “full-time student” status will be certified from January through September and/or from September through January.
However, you will not receive another mailing when the certification period has expired.
• You will need to:
- Proactively request, complete and return a completed Full-Time Student Dependent Certification form prior to each of the two periods
described above, or
- Re-certify your child once it’s apparent that their claims are being denied for lack of coverage (Highmark will hold the claim and send
you a blank Full-Time Student Dependent Certification form. If the form is not returned within thirty (30) days, you will be notified
that the claim has been denied. The claim will be reprocessed for payment only upon receipt of the properly completed Full-Time
Student Dependent Certification form.), or
- Pre-certify your student dependent before any claim is filed by sending Highmark a completed form each January and September.
• When a dependent of yours is no longer a full-time student, you must call Highmark at 1-800-245-6642.
For a medical claim return Full-Time Student Dependent Certification form to:
Highmark BCBS
USS Dedicated Unit
120 Fifth Avenue
Suite P3503
Pittsburgh, PA 15222
Prescription Drug Program:
• Certification of your student dependent is required before prescription drug benefits are paid.
• If the form is not returned within thirty (30) days, you will be notified that the claim has been denied. The claim will be reprocessed for
payment only upon receipt of the properly completed Full-Time Student Dependent Certification form.
• When a dependent of yours is no longer a full-time student, you must call Medco Health at 1-800-662-8269.
For a prescription claim return Full-Time Student Dependent Certification form to:
Medco Health Solutions of North Versailles, L.L.C.
Attn: Eligibility Department
1810 Lincoln Highway
North Versailles, PA 15137
Fax Number: 412-829-3245
Dental Benefits Program:
Dependent Certification is a service that United Concordia provides to its members. Prior to when your dependent child attains the limiting age
of coverage, United Concordia will send you a Dependent Certification Form to determine if your child is eligible for student dependent
status.
The Dependent Certification Form you receive must be returned within thirty (30) days in order to ensure timely processing. Completed forms
should be sent to: Dependent Certification, United Concordia Companies, P.O. Box 69417, Harrisburg, PA 17106-9417.
Form # IA-200 rev. 7/05