TRAINING CALIFORNIA DEPARTMENT OF HUMAN RESOURCES BENEFITS DIVISION Dental Enrollment Form blank sample Allows for New Enrollments Cancellation Changes Dental Enrollment Form Std 692 Revision February 2016 ID: 568863
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DENTAL ENROLLMENT FORMTRAINING
CALIFORNIA DEPARTMENT OF HUMAN RESOURCES
BENEFITS DIVISIONSlide2
Dental Enrollment Form –
blank sampleSlide3
Allows for:• New Enrollments
• Cancellation
• Changes
Dental Enrollment Form – Std. 692 Revision February 2016Slide4
SECTION A
Section A
Type of Action
New
Cancel – to cancel all dental coverage.
Changes
COBRA – does not get processed by SCOSlide5
SECTION B
1. DENTAL PLAN NAME
– need
full name
of dental plan name, not just Delta Dental.
2. Provider/Facility Number
(if applicable) – please provide the number only.
3. Employee and dependents name –
Legibility is important. 26 yr. olds not allowed, unless disabled, please note in the remarks section.
4. Relationship –
Verify Marital status.
5. Action Code –
A (add) or D (delete) only allowed!Slide6
Prepaid Plans
Box 1: Name of Dental Plan – please make sure the dental plan name matches with the dental code.
Box 2: Provider/Facility Number (if applicable) (prepaid plans only) – This number can be obtained from the employee’s dental office or through the dental carrier directly.Slide7
SECTION CSlide8
1. A box must be checked.
2. Employee’s signature.
3. Date employee signed the Std. 692.
Section DSlide9
Section ESlide10
2-Reminder for the STD 692
Do not forget to put in
permitting
e
vent date, permitting
e
vent
c
ode, and effective
date of action.
Any
information needed to process the
form,
add in the remarks section
.
Section
E, and
box 3 must be accurate.Slide11
Helpful Hints
When deleting twins, deletion can be on one form
.
The Permitting event must happen first.
Always audit the Std. 692 prior to submitting to SCO for processing.
If you can’t read the writing, then the carriers can’t either. This will cause a problem with accuracy.
Make sure the employee list all their dependents on the form, if they are making changes. Slide12
1-Reasons for SCO Enrollment Rejection
Permitting Event Code is missing or invalid.
Plan name and Org Code doesn’t match (Section B and E).
Party Code is missing or invalid.
Permitting event date is missing or invalid.Slide13
2-Reasons for SCO Enrollment Rejection
Event must happen first.
Standard events: date rec’d by employing office cannot be prior to the permitting event date.
Mandatory events: date rec’d at SCO can’t be prior to the permitting event date.
Section D is not checked. Slide14
3-Reasons for SCO Enrollment Rejection
Family member is missing, check against SCO HIST for party code.
When several permitting events are occurring, they must be submitted on separate forms.
All forms are to be signed by authorized agency personnel.Slide15
BENEFITS CALCULATOR
OVERVIEWSlide16
BENEFITS CALCULATOR
Go To:
CalHR
Website (www.calhr.ca.gov)
C
lick on:
State Employees
Scroll down to:
Health, Dental and VisionClick on:
Benefits CalculatorSlide17
Benefits Calculator – Select Year and Bargaining UnitSlide18
Benefits Calculator – Selected Year and Bargaining UnitSlide19
Benefits Calculator Select a Bargaining Unit Slide20
Benefits Calculator – select plan optionsSlide21
Benefits Calculator - Benefits Comparison
con’tSlide22
Benefits Calculator Results – error messageSlide23
Benefits Calculator Results – messageSlide24
Benefits Calculator Application Template – View/PrintSlide25
Dental Form, input required informationSlide26
Dental Form, input required
information,
con’tSlide27
Benefits Calculator - Open Your Benefits FormSlide28
Dental Enrollment Form Populates, Section A and BSlide29
Benefits Calculator Section C,
Section DSlide30
Dental Enrollment Form, Section ESlide31
Dental Program Coordinators
Sandra Lobatos-Chico
Christina Campbell
Anne
Santos
Phone Number: 916-322-0300
Fax: 855-290-0158
Email: dental@calhr.ca.gov