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.
Before submitting a claim, determine who the primary insurer is. General rules appear below.
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).
For healthy newborns receiving nursery care, the mother’s plan is primary is most cases. For other dependents:
|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.
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.
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.