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    v1.0.30
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyAetna Benefit Reserve for Secondary Plans Policy U…
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    CurrentAetnaPolicy N/A

    Coordination of Benefits — Benefit Reserve for Secondary Plans

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    Governance of how secondary health benefit plans compute and use a benefit reserve to ensure total payments across plans do not exceed allowable expenses; applies to health insurance plans subject to Louisiana Administrative Code regulation on coordination of benefits.

    Policy Summary
    PayerAetna
    PolicyCoordination of Benefits — Benefit Reserve for Secondary Plans
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewApr 1, 2018
    Next Review DateN/A
    Key ActionSecondary plans must establish and maintain a benefit reserve account for each covered person and apply savings from paying less than primary liability to that account to cover other allowable expenses within the claim determination period.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsminimum claim determination period
    100%maximum total benefits payable across plans

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5illustrative claim examples provided
    26example Plan A visit limit

    Benefit Reserve — Calculation & Application

    Benefit Reserve Calculation and Application

    Procedure secondary plans must follow to compute savings and apply benefit reserve:

    Secondary plans must establish and maintain a benefit reserve account for each covered person and use savings from paying less than primary liability to pay other allowable expenses during the claim determination period (a period of time not less than 12 months).

    ALL of the following

    • Determine how much the secondary plan would have paid if it had been the primary plan.
    • Subtract the amount the secondary plan actually paid on the claim from the amount it would have paid as primary to calculate the savings for that claim.
    • Place the difference (savings) into the covered person's benefit reserve account.
    As subsequent claims are submitted during the same claim determination period, the secondary plan must review prior claims and apply available savings from the benefit reserve to pay allowable expenses that would not otherwise be paid, including amounts previously applied to either plan's deductible, coinsurance, or copayment.

    ALL of the following

    • Use the accumulated savings to pay outstanding allowable expenses from earlier claims to the extent savings are available (example: use savings from a later 100% payable claim to pay a prior deductible balance).
    • Respect relative value schedule (RVS) limits when determining allowable amounts; the insured may be liable for any difference between the actual charge and the highest RVS amount, and savings are based on the difference between what the secondary plan would have paid as primary and what it actually paid (see RVS example).
    Claims that exceed the primary plan's covered limits are not allowable beyond the primary plan's limit; benefit reserve may only be used for amounts considered allowable expenses under the primary plan (illustrated in the spinal manipulation example where only 26 visits are allowable).

    Coding & Administrative Parameters

    Relative value schedule (RVS) adjustmentsmixed
    No codes listed
    Claim determination period length
    Minimum lengthClaim determination period: a period of time not less than 12 months
    Typical examplesUsually a calendar year or contract year
    Purpose within COBPeriod during which total benefits paid by all plans must not exceed total allowable expenses

    Provider / Plan Operational Requirements

    Documentation Required

    Benefit Reserve Establishment and Use — establish account and apply savings

    Secondary plans must establish and maintain a benefit reserve account for each covered person and apply savings from paying less than primary liability to that account to cover other allowable expenses within the claim determination period. The plan must (1) determine what it would have paid if it had been primary for each claim, (2) subtract that amount from what it actually paid, (3) place the difference (savings) into the covered person's benefit reserve account, and (4) apply savings from the benefit reserve to pay allowable expenses on subsequent claims (including amounts previously applied to either plan's deductible, coinsurance or copayment) during the claim determination period (a period of not less than 12 months).

    • Determine, for each claim, how much the secondary plan would have paid if it had been the primary plan.
    • Subtract that amount from what the secondary plan actually paid; place the difference into the covered person’s benefit reserve account.
    • Use savings in the benefit reserve to pay allowable expenses on subsequent claims during the claim determination period, including claims previously applied to either plan’s deductible, coinsurance, or copayment.
    • Claim determination period is a period of time not less than 12 months (usually a calendar or contract year).

    Key Terms

    Benefit reserve — definition
    DefinitionBenefit reserve account: an account established and maintained by the secondary plan for each covered person to hold savings from paying less than the primary liability
    Source of fundsDifference between what the secondary plan would have paid as primary and what it actually paid as secondary (savings placed into the account)
    Permitted useUsed to pay allowable expenses for the covered person during the claim determination period that would not otherwise be paid
    Application orderAs subsequent claims are submitted, the secondary plan reviews prior claims and applies benefit reserve funds to pay allowable expenses (including amounts applied to deductibles, coinsurance, or copayments)
    Claim determination period — definition & examples
    Definition
    Policy Summary
    PayerAetna
    PolicyCoordination of Benefits — Benefit Reserve for Secondary Plans
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewApr 1, 2018
    Next Review DateN/A
    Key ActionSecondary plans must establish and maintain a benefit reserve account for each covered person and apply savings from paying less than primary liability to that account to cover other allowable expenses within the claim determination period.
    SourceLink
    On This Page
    Benefit Reserve — Calculation & ApplicationCoding & Administrative ParametersProvider / Plan Operational RequirementsKey Terms
    Claim determination period: a period of time not less than 12 months during which coordination calculations apply
    Common examplesUsually a calendar year or a contract year
    Role in coordinationDefines the time window in which total benefits from all plans cannot exceed total allowable expenses and within which benefit reserve funds must be applied