Wednesday, May 26, 2010

Coordination of Benefits - Denial

coordination of benefits

Coordination of benefits (COB) is the process of sharing liability when a member has coverage with more than one health insurance policy covering similar services. We will make every effort to pursue COB revenue when another carrier is responsible for primary coverage.

Guidelines for determining primary coverage

When a member is covered by two or more health insurance policies and a service is received that may be covered in part by either plan, we will coordinate benefit payments with the other carrier. Our payment will be up to the allowable expense defined as “necessary, reasonable, and customary items of expense.” The other carrier(s) will provide secondary benefits, if necessary, to cover the member’s expenses. This prevents duplicate payment and overpayment.


Determining primary carriers

1. The plan that does not have a clause or does not comply with Regulation II NYCRR 52 is primary.

2. The plan that covers the person as an employee, member, or subscriber is primary before a plan that covers the person as a dependent.

3. If two or more plans cover an individual as a dependent child of divorced or separated parents, benefits for the child are determined in this order

The plan of the parent with custody of the child is primary
• The plan of the spouse of the parent with custody is secondary
• The plan of the parent not having custody of the child is tertiary 


4. When two plans cover the same child as a dependent of both covered parents, the following applies:

• Parent’s birthday: Plan benefits of the parent whose birthday falls earlier in the year are determined before those of the parent whose birthday falls later in the year.

• Parents with same birthday: If both parents have the same birthday, the benefits of the plan that covered the parent longer are determined before those of the plan that covered the other parent for a shorter period of time.

 If the other plan does not have the rule described above, but instead has a rule based upon gender of the parent – and if, as a result, the plans do not agree
on the order of the benefits, the rule in the other plan will determine the order of benefits.

 Note: “Birthday” refers only to month and day in a calendar year, not the year the person was born.

5. Primary coverage as an employee:

• The benefits of a plan that cover a person as an active employee who is neither laid off nor retired are determined before those of a plan that covers that person as laid off or retired.

• If the other plan does not have this rule and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.

6. If none of the above rules determine the order of benefits:

• The benefits of the plan covering an employee, member or subscriber the longest are determined before those of the plan covering that person for a shorter time.


Guideline form Horizon NJ

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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