NCFlex Exception Request Form

Form for Health Benefit Representative (HBR)/Authorized Personnel use only. AN EXCEPTION SUBMITTED BY AN EMPLOYEE WILL BE DECLINED. Complete this form to ask for an exception to the NCFlex Program Benefit Rules outside a Qualifying Event.

Name Of Health Benefit Representative or Authorized Personnel*

E-mail Address*

Health Benefit Representative Phone Number*

Is this a University Employee?

Please indicate if this is a university (or constituents) employee. This lets us know that the Empyrean platform may also need to be notified.

Name of Work Location (Non-University)*

Select or enter value

Name of Work Location (University)*

Select or enter value

Last Four Digits of Employee's SSN*

Please ensure number is accurate!

Please do not include full SSNs on this form.

Employee's Full Name*

As listed in the enrollment system.

Employee ID#

Not SSN

Dependent(s) Name*

Please have employee add dependent(s) in the enrollment platform with valid SSN and DOB prior to submitting the exception (don't include SSN or DOB on this form). If they are not able to add dependents themselves, they can call the enrollment support line at 1-855-859-0966. If no dependents are being requested on the plan(s), put N/A.

Date of Employee's request*

Date employee notify the HBR.

Reason for request*

Select or enter value

List NCFlex Benefit(s) Affected*

Include type of benefit (dental, vision, etc.), level/coverage amount (low, high, enhanced, GTL $150k, etc.), and who is covered (ee only, ee + child, etc.). Also, if dependents are being covered, please identify which dependents listed above should be covered on which benefits. Please do not include premium amount in place of coverage level.

Effective Date*

Effective date should be 1st of the month following the date of event. For Open Enrollment exceptions, effective date is January 1st. If EOI is required, effective date is 1st of the month following approval.

Please Explain the reason for the Exception*

Why was the window missed, what is/was the life event, was this an Admin or Employee error, what resolution is expected, etc.

Exception or Appeal*

Select or enter value

Has documentation been uploaded and approved?

If the exception is related to a QLE that requires documentation, please ensure that documentation is uploaded and approved in the enrollment system and check the box below.

Attach documentation

Provide any documentation that may assist with the decision.

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