Wednesday, May 26, 2010

Coordination of Benefits - Denial

Any services provided to a Horizon NJ Health member is reviewed against benefits provided for that same individual under other insurance carriers with whom the member has coverage. Horizon NJ Health, as a managed care program for Medicaid and New Jersey FamilyCare members in New Jersey, is the “payor of last resort” on claims for services provided to members
also covered by Medicare, employee health plans or other third party medical insurance. Payors which are primary to Horizon NJ Health include (but are not limited to):

• Private health insurance including assignable indemnity contracts
• Health Maintenance Organizations (HMOs)
• Public health programs such as Medicare
• Profit and non-profit health plans
• Self insured plans
• No-fault automobile medical insurance
• Liability insurance
• Worker’s compensation
• Other liable third parties

In cases where another insurer, other than Medicare, is deemed responsible for payment, Horizon NJ Health will pay the difference between our maximum allowable expense and the amount paid by the primary insurer provided this amount does not exceed the lowest contractually agreed amount and does not exceed the normal Horizon NJ Health benefits which would
have been payable had no other insurance existed. When you provide services to a member who has any other coverage, bill the member’s primary insurer directly. Make sure that you follow that insurer’s standard claim submission policies and forms.

Upon receipt of payment, submit applicable claims to Horizon NJ Health for payment of deductibles and coinsurance amounts. Horizon NJ Health reimburses after coordination of benefits and only up to the primary contracted rate for the service. The claim, PCP referral and the primary insurer’s Explanation of Benefits (EOBs) must be submitted within 60 days of the date of the EOB or within 180 days of the dates of service, whichever is later.

When preparing the claim, include a complete record of the original charges and primary (or additional) payor’s payment as well as the amount due from the secondary or subsequent payor. Submit all pages of the primary (or additional) insurer’s EOB to avoid delays in completing claims due to missing information or coding and message descriptions. This information ensures accurate coordination of benefits. 

With the exception of Medicare, Horizon NJ Health’s same notification policies that are routinely applied and required must be followed for any claims to be considered for payment.

IMPORTANT – All Coordination of Benefit (COB) claims must be submitted with a copy of the EOB from the primary insurer.

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