"If the information on file with the carriers is accurate and the claim is submitted to the secondary insurer in error, it will be kicked out pending receipt of the primary carrier's EOB. This article will provide you with everything that you need to know about coordination of benefits. 2. Let's say you visit your doctor and the bill comes to $100. That's corrected easily enough, but can be a headache for the provider's office. Mich. Aug. 28, 1998)]. The COB provisions that are specified in the insurance policy outline which plan is the primary plan. How to Understand the Coordination of Benefits Rule in Health Insurance. Then, the secondary plan picks up its part of the cost up to 100% -- as long as the services are covered by that insurer. All Rights Reserved. The insured can then contact the medical provider to have them rebill the claim to the primary carrier," said Walsh. Under the generally recognized definition of a coordination of benefits clause in an insurance policy, a provision need only be conditioned on the existence of other insurance and establish an order of payment between the plans. Image Credit: Pictures of Money , via Flickr Creative Commons (Visited 15,527 times, 1 visits today) You don't want to get an expensive test thinking that both plans will cover it and find out later that the secondary insurance company doesn't cover that service. That sounds great, right? UpCounsel accepts only the top five percent of lawyers to its site, and these professionals come from schools such as Harvard Law or Yale. This secondary insurance plan can take the benefits of the patient's other plans into consideration only when it has been confirmed as being the secondary — not primary — plan. Don't assume that both insurers have the same rules. It's more difficult to resolve issues involving large employer self-funded plans because they are under their own COB rules. Let's say that's $50. The benefits are usually coordinated between all of the plans held by the patient. COB can vary by plan, so Kathy Walsh, principal examiner in the consumer affairs unit of the Connecticut Insurance Department, said it's important to "do your homework to determine if it is advantageous to carry both plans before you enroll.". Co. v. Morton Bldgs., 1998 U.S. Dist. There may be some differences to the "order of benefit determination" as laid out here if the claimant's policy is held with Medicare, but otherwise, these rules should be followed as a standard process. The primary insurance plan is given the responsibility of being the first payer, the secondary plan is the second payer, and so on depending on how many plans the individual holds. A lack of coordination between the plans a person holds can result in the claim not being paid until the COB has been confirmed, thus potentially causing financial difficulties. If you find the secondary payer will cover the entire balance that's left after the primary plan, Walsh said it may be beneficial to carry both plans. Was this document helpful? In that case, you would need to contact the U.S. Department of Labor at 877-267-2323 or visit www.askebsa.dol.gov to help you with your COB problems. This is especially true if your insurance plans have different types of plan design, such as a PPO and HMO. Share it with your network! LEXIS 14976 (W.D. Once you determine the second payer, you'll also want to contact that insurance company to determine if the health plan will pay the entire out-of-pocket expenses after the primary insurer pays. Compensation may impact where products appear on Insure.com (including the order in which they appear).QuinStreet does not include all insurance companies or all types of products available in the marketplace. No need to spend hours finding a lawyer, post a job and get custom quotes from experienced lawyers instantly. 1. Walsh said COB issues are usually resolved easily when the problems involve insurance policies in the same state.
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