Dependent Out-Of-Area Benefit Form - West Virginia Public Employees Insurance Agency

ADVERTISEMENT

Dependent
Out-of-Area Benefit Form
Out-of-area benefits are available to dependents who reside outside PEIA’s service area.
PEIA’s service area includes all of West Virginia, and bordering counties of surrounding states.
If you have a dependent who lives outside PEIA’s service area, then you must complete this
form to receive the in-network level of benefits without seeking prior authorization for all
services. Services must be provided by PPO providers.
PEIA’s Preferred Provider Benefit (PPB ) plan requires prior approval for all services
provided outside PEIA’s service area for members who reside within the service area. The
service area is defined as all West Virginia counties and all counties that border West Virginia.
Counties beyond this border are considered out-of-area. However, dependents who reside outside
PEIA’s service area are eligible for a waiver of the prior approval requirement by completing
this form.
Complete the following information for each dependent who you believe qualifies for out
of-area benefits. Forward this form to HealthSmart Services at PO. Box 2451, Charleston,
WV 25329-2451. You will receive written notification of the status of this request.
Employee Name ____________________________________________________________________
Employee Social Security Number _____________________________________________________
Employee Home Address _____________________________________________________________
Employee City _______________________________ State _____ County __________Zip _______
I believe the following dependents are eligible for Out-of-Area Benefits:
Name______________________________________________________________________________
Relationship to Employee ____________________________________________________________
Date of Birth _______________________________________________________________________
Address____________________________________________________________________________
City ________________________________________ State
County __________Zip _______
Name______________________________________________________________________________
Relationship to Employee ____________________________________________________________
Date of Birth _______________________________________________________________________
Address____________________________________________________________________________
City ________________________________________ State _____ County _________Zip _______
Signed_________________________________________________ Date ______________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go