Membership Enrollment Form - Delta Dental Of Minnesota (Page 2 of 2) in pdf

Employer Instructions

x Review Parts A, B, C, D, E, F and G to be sure all information is complete, accurate and legible.

x When reporting effective dates use contractual start and stop guidelines as defined in your contract (i.e., 1

of month,

end of month, or actual dates).

x Delta Dental of Minnesota generally completes enrollment requests within five business days of receipt.

Complete Part H - Group Enrollment Information

x Check one reason for enrollment and provide requested information including coverage effective dates.

x New Group – New customer to Delta Dental and submitting initial employee enrollment. Complete the Prior

Coverage Start Date only if your plan benefits include waiting periods and credit for prior creditable coverage

applies. Note: For a New Group enrolling a Direct Billed COBRA participant, write Direct Bill in the New Group

section. If information is not provided, participant will not be enrolled and billed properly.

x Existing Delta Dental Group – Enrolling additional employees from an acquisition/merger who were not previously

offered/enrolled in you Delta Dental plan. Complete the Prior Coverage Start Date only if your plan benefits include

waiting periods and credit for prior creditable coverage applies.

x New Hire – Enroll newly hired employee. If a probationary period applies, the coverage effective date is after the

probationary period.

x Open Enrollment – An employee is enrolling during group’s open enrollment period.

x Rehire – A former employee was rehired.

x Return From Leave of Absence – An employee is returning from leave of absence.

x Employee Status Change – The employee’s employment status changed and the employee is now eligible for

dental benefits.

x Previously Waived Coverage or Loss of Coverage – If an employee waives coverage, he/she can only enroll at a

later date if the group contract includes an Open Enrollment period or if the individual has a loss of other insurance

coverage. If an employee or dependent involuntarily losses coverage and are now eligible to enroll, complete this

section.

x Group Name – Provide group name as listed in your contract.

x Group and Subgroup Number – Provide applicable numbers for individual employee.

x Group Representative – Sign, date, and provide your phone number.

Send Completed Forms To:

Delta Dental of Minnesota

Attn: Enrollment Department

PO Box 330

Minneapolis MN 55440-0330

Membership Enrollment Form - Delta Dental Of Minnesota Page 2