CurrentBlue Cross Blue Shield - ArizonaPolicy N/A

Coordination of Benefits and Subrogation

Defines coordination of benefits (COB), primary payer rules, Medicaid (AHCCCS) interaction, payment methodology, and subrogation stance for ACA StandardHealth with Health Choice individual/family policies issued by Blue Cross Blue Shield of Arizona; affects members, providers, and claims processors.

Policy Summary

PayerBlue Cross Blue Shield - Arizona

PolicyCoordination of Benefits and Subrogation

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit all claims and copies of explanations of benefits from other carriers to BCBSAZ and provide requested COB information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

BCBSAZ or MedicareCoordinates only with

BCBSAZ primaryAHCCCS ordering

No subrogationSubrogation stance

Not coordinatedMedical vs Dental

ExcludedPharmacy services

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Coverage and Coordination Rules

Primary Payer Determination

Primary payer order when multiple BCBSAZ non-group policies exist:

When benefits for covered services are payable under the member's ACA StandardHealth with Health Choice individual/family policy and one or more additional BCBSAZ non-group policies, apply the following order of benefits:

Order rules

If the member is covered as a policyholder under one policy and as a dependent under another, the policyholder's coverage pays first.
If a child is covered under a 'child-only' policy, the child-only coverage pays first.
For dependent children, if either plan is a non-group contract, the non-group contract pays first.

Medicaid / AHCCCS

Medicaid (AHCCCS) interaction:

If a member also has coverage through the Arizona Health Care Cost Containment System (AHCCCS) or another state Medicaid agency, BCBSAZ coverage is primary; submit the claim to BCBSAZ for adjudication as the primary payer.

BCBSAZ and AHCCCS share eligibility information to assist AHCCCS health plans in identifying members who also have private coverage; if an AHCCCS plan pays primary in error, AHCCCS may seek recoupment and BCBSAZ will remit payment to the AHCCCS health plan when we have not previously received and adjudicated the claim, in compliance with the member's benefit plan and A.R.S. § 36-2923.

Payment Methodology and Exclusions

Payment methodology and exclusions:

We do not coordinate benefits between separately purchased medical and dental plans.

We do not coordinate benefits for covered services provided by a retail or mail-order pharmacy.

Members must provide requested coordination-of-benefits information to BCBSAZ and are responsible for billed charges until the information is received.

All claims and copies of explanations of benefits from other carriers should be sent to BCBSAZ for processing.

Medicare coordination references

Refer to CMS Medicare Secondary Payer guidance for Medicare coordination rules.

Subrogation

Subrogation stance:

Subrogation procedures are used to recover claim payments from responsible third parties or their insurers when a member's illness or injury may be the responsibility of another payer.

Arizona is considered a 'no subrogation' state; for fully insured plans, BCBSAZ does not pursue subrogation to obtain payment from the responsible third party.

Provider Submission and Billing Requirements

Billing Rule

AHCCCS primary submission

When a member has AHCCCS (Arizona Medicaid) coverage in addition to a BCBSAZ Health Choice/ACA StandardHealth individual or family plan, submit the claim to Blue Cross Blue Shield of Arizona for adjudication as the primary payer. BCBSAZ and AHCCCS share eligibility information to help identify members with dual coverage. If an AHCCCS health plan pays as primary in error, AHCCCS may seek recovery from BCBSAZ; in those cases, if BCBSAZ has not previously adjudicated the claim, BCBSAZ will remit any payment due directly to the AHCCCS health plan in accordance with the member's benefit plan and A.R.S. § 36-2923.

Note

Claims submission and information requirements

Submit all claims and any copies of explanations of benefits from other carriers to BCBSAZ for processing. Members must provide requested coordination-of-benefits (COB) information to BCBSAZ and will be responsible for billed charges until that information is received. Note that BCBSAZ does not coordinate benefits between separately purchased medical and dental plans, nor for covered services provided by retail or mail-order pharmacies. For Medicare coordination rules and the BCBS Medicare 'crossover' process, see Section 19.

Policy Scope and Key Definitions

Non-group policy

Policy typeACA StandardHealth with Health Choice individual/family (non-group) policies.

Coordination scopeThese non-group policies do not coordinate benefits with other commercial carriers; they coordinate only with another BCBSAZ policy or Medicare.

Primary over group plansWhen benefits are payable under the non-group policy and one or more BCBSAZ group plans, benefits are paid first under the non-group policy.

No subrogation (Arizona)

Arizona subrogation stanceArizona is considered a 'no subrogation' state; for fully insured plans BCBSAZ does not subrogate to obtain payment from the responsible third party.

General subrogation rightPayers have the legal right to recover any claim payments from the responsible party or their insurance company (general principle).

ScopeSubrogation procedures apply when a member has an illness or injury for which a third party or other payer may be responsible, except as noted for Arizona fully insured plans.

OpenPayer

Coordination of Benefits and Subrogation

Coverage and Coordination Rules

Coding and Payment Limits

Provider Submission and Billing Requirements

Policy Scope and Key Definitions