Eligibility and Policy Term Violations - Definitions
(1) “Eligibility or Enrollment Violations” means and includes a violation of the PEBB’s eligibility or enrollment rules or policies including fraud or material misrepresentation. Misstatements, misrepresentations, omissions or concealments on the part of the PEBB member are not fraudulent unless they are made with intent to knowingly defraud. PEBB has primary responsibly in investigating such violations. If an Eligibility Violation is considered a violation of the insurance carrier’s policy, then the violation may also be considered a Policy Term Violation, and OAR 101-015-0040 (Policy Term Violations) would also apply.
(a) “Intentional Violation” is a violation that has occurred in which PEBB has electronic or written documentation that the eligible employee took action resulting in a non-eligible member being enrolled in PEBB benefits.
(b) “Unintentional Violation” is a violation that has occurred in which the eligible employee was not aware that such violation had occurred and there is no evidence of the eligible employee completing a paper form or logging in and enrolling an ineligible member in PEBB benefits.
(2) “Policy Term Violations” means and includes a violation of the insurance carrier’s policy terms. The insurance carrier has primary responsibility in investigating such violations.