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When members have more than one insurer
November 2, 2020

This article is for dentists caring for our members

When a member is covered by more than one insurer, rules called “coordination of benefits” ensure the correct insurer pays the member’s claim. However, sometimes patients don’t let us know that they have another insurer, which can cause us to pay their claims incorrectly.

Please ask patients to let us know about any other insurer they have. This will save you time and paperwork caused by any recoveries necessary to collect money paid in error. We’ve created a fact sheet that you can print out from our website to help educate your patients.

Other coordination of benefit tips

The following tips may help you manage claims more efficiently when your patient is covered by more than one insurer:

  1. Submit your claim to the patient’s primary payer first. To determine the primary payer:
    If your patient Then
    Is the subscriber on the plan The subscriber’s plan is primary.
    Has two plans The plan that has been in effect longest is primary.
    Is a dependent over age 19 The “birthday rule” applies. The parent whose birthday falls first in the calendar year is primary.
    Is a dependent under the age of 19 who is covered under the Essential health Benefits for pediatric dental Their medical plan is primary.

  2. Submit the primary payer’s Explanation of Benefits (EOB) to the secondary payer.
    • Remember that the secondary payer’s EOB may not correctly reflect the patient balance, and that your patient’s liability may be affected by contracts that you hold with the primary carrier.
    • When the member has both medical and dental benefits with us as the secondary payer, we will not pay more than the remaining member balance reflected on the primary plan’s EOB/Provider Detail Advisory.

Note: We cannot accept a pre-treatment estimate from the primary carrier. This must be a clearly identified EOB.

Keep in mind that you can submit for coordination of benefits only when the member has a liability. You may not bill for coordination of benefits to collect any “adjusted” fee amount your office may have incurred.

Our coordination of benefits area includes a link to the member fact sheet discussed above, as well as information about:

  • Determining which payer is primary
  • Submitting claims when there is more than one payer
  • Handling rejected claims
  • Submitting claims when Medicare is primary