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Coordination of Benefits Form for Young Adult Coverage1199SEIU Benefit Funds 2026

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The document is a Coordination of Benefits Form for Young Adult Coverage provided by the 1199SEIU Benefit Funds. It outlines the process for members to request health insurance coverage for their dependent children aged 19 to 26. The form requires detailed information about both the member and the young adult dependent, including eligibility for other health plans through parents, employers, or spouses. It emphasizes the importance of completing and submitting the form accurately to avoid gaps in coverage.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the MEMBER’S INFORMATION section. Clearly print your full name, member ID, and contact details including address, phone numbers, and email.
Indicate the benefit fund(s) you are enrolled in by checking all applicable boxes.
Proceed to the YOUNG ADULT’S INFORMATION section. Fill in your dependent’s full name, social security number, and contact information if different from yours.
Answer questions regarding other health plans your young adult may have through their other parent, employer, or spouse. Provide necessary details such as employer names and types of coverage.
Review all entries for accuracy. Once completed, print the form, sign it along with your young adult dependent, and date it before submission.

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What is the purpose of the coordination of benefits clause?

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an

How does the cob work?

The coordination of benefits (COB) process determines the order in which multiple insurance providers are billed, effectively preventing duplicate payments and reducing the overall cost of healthcare for patients.

Who is eligible for 1199 local benefit fund?

Members are generally eligible for benefits after they have been working for a contributing employer for 180 days or more, in most cases, except for Genesis and Actors Fund employees, who become eligible after 90 days. If you have questions about your eligibility, call the Fund at (646) 473-9200.

What do you mean by coordination of benefits?

Coordination of Benefits is a provision that determines the sequencing of coverage when Plan members and their dependents are eligible for benefits under more than one private health care plan. The PSHCP uses the benefit coordination guidelines established by the Canadian Life and Health Insurance Association (CLHIA).

What is a coordination of benefits claim?

COB is a process where individuals, couples or families with more than one benefits plan combine their benefits coverage. This allows a plan member to receive up to the maximum eligible amount for eligible prescription drug, dental and health COB claims.

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What is a coordination of benefits form?

Coordination of benefits (COB) is part of the insurance payment process. It is how insurance companies decide who covers the cost of your care in a given situation. Insurance companies follow general principles to establish the order each company will pay.

What is the payer ID for 1199 local benefit fund?

Payer Identification Number Number To submit electronic claims, providers must use the 1199SEIU Benefit Funds payer identification number, which is 13162.