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e. Information Needed When You Call CareCheck®. When you or another person contacts CareCheck®,this information is needed: • the covered person's name,address,phone number,birth date and ID number; • the attending physician's name,address, and phone number; • the facility's name,address, and phone number; • the reason for the services requiring review,as shown in a. above. f. Pre-certification Process. When a pre-certification for a non-urgent service is requested from HealthPartners, an initial determination must be made within 15 calendar days.This time period may be extended for an additional 15 calendar days, provided that the Plan Manager determines that such extension is necessary due to matters beyond the control of the Plan. If such extension is necessary, you will be notified prior to the expiration of the initial 15-day period. When a pre-certification for an urgent service is requested from HealthPartners, an initial determination must be made within 72 hours, so long as all information reasonably needed to make a decision has been provided. In the event that the claimant has not provided all information necessary to make a decision, the claimant will be notified of such failure within 24 hours. The claimant will then be given 48 hours to provide the requested information. The claimant will be notified of the benefit determination within 48 hours after the earlier of HealthPartners receipt of the complete information or the end of the time granted to the claimant to provide the specified additional information. How to contact CareCheck®: You may call(952)-883-5800 in the Minneapolis/St. Paul metro area,or 1-800- 942-4872 outside the metro area, from 8:00 a.m. to 5:00 p.m. (Central Time) weekdays. You can leave a recorded message at other times. You may also write CareCheck® at Quality Utilization Management Department,8170 33"'Avenue South,P.O.Box 1309,Minneapolis,MN 55440-1309. F. ELIGIBILITY, EFFECTIVE DATE, LATE ENROLLMENT, SPECIAL ENROLLMENT PERIOD, • NEWBORN ENROLLMENT,CHANGES IN BENEFITS AND TERMINATION 1. ELIGIBILITY. All employees, as determined by the employer,working 20 hours per week(actively at work) are eligible to enroll in the Plan. The employee must make written application to enroll the employee and any eligible dependents,and such application must be received by the employer within 31 days of the date they first become eligible. The employee must make written application to enroll a newly acquired dependent(such as a new spouse) within 31 days of when the new dependent is first acquired. There may be additional situations when the employee is eligible to enroll after the first 31 days of eligibility. If there are any questions, contact the employer and see"Late Enrollment"below. 2. EFFECTIVE DATE. Provided the employee is actively at work on that date, the employee's and any dependent's effective date is the fust of the month following completion of the following waiting period: 30 days of active work with the employer. An employee must be actively at work on the initial effective date of coverage or coverage for the employee and dependents will be delayed until the date the employee returns to work. The effective date of coverage shall not be delayed if the employee is not actively at work due to the employee's health status, medical condition,or disability. For purposes of this provision, "actively at work" is the time period in which an employee is customarily performing all the regular duties of his/her occupation at the usual place of employment or business,or at some location to which that employment requires travel. An employee is considered actively at work for the time period absent from work solely by reason of vacation or holiday, if the employee was actively at work on the last preceding regular workday. CON-700.6 SIHPOA 5105-06 20