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Coordination of Benefits

When a member has more than one insurer covering his or her health care costs, the insurers need to coordinate payment. The primary insurer must process the claim first. The claim is then submitted to a secondary or tertiary insurer with the explanation of benefits from the primary insurer. These are often called "coordination of benefits" claims.

Dentists, please note: benefits are not coordinated for pre-treatment estimates.

Who is the primary insurer?

Before submitting a claim, determine who the primary insurer is. General rules appear below.

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Medical and dental coverage

When the member has both dental and medical coverage through us and either policy would cover the services, our medical plan is considered primary (except for FEP members).

Married couples

For married couples:

  • With no Medicare, who are each covered by their own active employer group plan, each spouse is primary on their own plan and secondary on their spouse’s plan.
  • With both Medicare and an active Federal Employee Program policy, FEP is primary.
Healthy newborns and other dependents

For healthy newborns receiving nursery care, the mother’s plan is primary is most cases. For other dependents:

  • If the parents are married or living together, the plan of parent whose birthday falls first in the calendar year is primary.
    • If the married parents have the same birthday, the plan that has been in effect longer is primary
  • If the parents are not married or living together:*
The plan of: Is:
The parent with custody Primary
The spouse of the parent with custody Secondary
The non-custodial parent Tertiary

* These provisions apply in the absence of a specific court decree assigning responsibility for the health care expenses of the child to a particular parent.

Reimbursement for coordination of benefits claims

We will pay the balance up to the amount we would have paid if we had been the primary insurer. Please note that some accounts may elect maintenance of benefits payment calculations that may result in a lesser payment.

Patient liability

Before you calculate the patient’s liability, wait until you have received all payers’ EOBs. Once all insurance payments have been made, calculate your patient’s liability by claim line rather than using the total claim payment amount.

  • Dental services. You may only charge the member up to the fee schedule amount for additional services in that calendar year for services that would otherwise be covered. This change applies to all benefit limits for any services that are covered, including:
    • Annual maximums (calendar year and plan year) and orthodontic lifetime maximums
    • Time limits
    • Frequencies.

Resources

Member Fact Sheet

 Coordination of Benefits Questionnaire

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