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Enrollment Instructions

Please refer to the sample Medical Insurance Enrollment form:

  1. Action--check the box most appropriate to the action you hope to accomplish.
  2. Title--check one, and only one, title for the eligible enrollee. If the enrollee is a MD with hospital clinical privileges, they are a Resident or a Clinical Fellow. If they do not have a hospital appointment and are engaged in research only, they are a Postdoctoral Scholar (also referred to as a Research Fellow).
  3. Carrier--check one box to enroll member (and dependents) in one or the other medical plan: Health Net or Blue Cross, as per their choice. Enrollment in dental, vision, life, AD & D, as well as LTD is automatic (and mandatory) upon enrollment with one of the two health carriers.
  4. Personal Information--the carriers need all this information to enroll an individual. A California address or box number is required by Blue Cross; a local address is required by Health Net. The address given is the one to which the enrollment information will be mailed, so please be sure it's correct, and have your Department contact Human Resources office if there are any changes.
  5. Social Security Number Required!--We cannot process enrollment without the SSN. Our database, as well as those of all our insurance carriers are keyed on the SSN. If the individual is still waiting for the SSN, please call Human Resources for a temporary number and notify Human Resources when the permanent number is received. Effective January 1, 2004, the insurance carriers will replace the SSN on the enrollment cards with a unique insurance number to insure privacy.
  6. Department, Start & End Date Information--it is important that we know what department and unit an individual is affiliated with, and how to reach that unit. And of course, we must know the start date. The Fiscal Year End date is the end date for all enrollees; that date is automatically extended with the latest fund/dpa numbers each July to the new fiscal year end date unless the enrollee is terminated. Appointment end dates do not establish insurance end dates--insurance must be terminated with an insurance form.
  7. Dependent Information--Carriers require the following information to enroll dependents: dependent's SSN, birth date, gender and relationship to the enrollee. Where a Domestic Partner is to be registered an Affidavit of Domestic Partnership must be completed and returned with the enrollment form to our office.
  8. Enrollee's Signature--Must have signature and date of enrollment on the form, or it will not be processed. Also, the date must be within the 30 day Period of Initial Enrollment (PIE).
  9. Complete Accounting Information--We need to know where to charge insurance costs. Be sure you have set up the necessary DPA-Fund linkages with Accounting. Where Fund Year is assigned, it must be included for Accounting to process the transaction. Because the Natural Class Account (434895) is constant for the Resident and Postdoctoral Scholar Insurance Recharges, we have added it to the Accounting forms. The accounting section of the insurance enrollment form or an attached rotation schedule for residents can be used to provide funding information. For funding changes after the initial enrollment, use the RAD (Recharge Authorization from Department) form or the rotation schedule for Residents..
  10. Chair, Program Director or P.I. Signature--Required. For Residents and Clinical Fellows, we need the Program Director or Department Chair�s signature. For Postdoctoral Scholars, we need the authorized signature for the FUND/DPA to which insurance will be charged, i.e., Principal Investigator (on grant funds), the Program Director, Department Chair or MSO.
  11. Contact Person Name--Since your responsibility as Departmental Contact person is to keep track of all insurance enrollments, charges, changes, and terminations for your enrollees, we will not process any insurance action that you do not know about. If you sign the form, we will process it.
  12. Distribution--Send the original form to the Human Resources office and retain one copy for your file and one copy for the Resident or Fellow.

Be sure to inform your Residents and Postdoctoral Scholars that their insurance will become effective on the enrollment date printed on the form. However, due to the volume of enrollments in the Human Resources office and with the insurance carriers, during the months of June and July, it may take some time to get the trainee registered into the carrier�s system. Once registered, the trainee will receive mailings from Health Net or Blue Cross regarding their enrollment, usually within 4 - 6 weeks. Of course, if there is a medical emergency, contact the Human Resources office, and we will immediately take appropriate action. It is recommended that the enrollee keep a copy of the enrollment form with him/her until the membership card is received. This substantiates that a membership is pending and the membership effective date.