Currentblue cross blue shield - michiganPolicy N/A

About Blue Care Network coordination of benefits

Explains how Blue Care Network coordinates health and prescription coverage when members have more than one payer, who pays first, claim processing, out-of-pocket reimbursements, and how members should respond to information requests; applies to BCN members and providers submitting claims.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAbout Blue Care Network coordination of benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor drug claims, members must follow BCN's authorization requirements even when BCN is the secondary payer.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

questionnaire requiredmember action to help process claims

Member Reimbursement Formreimbursement process

CMS guidelinesMedicare rule source

applies when secondarydrug prior-authorization

When Blue Care Network Is Secondary — Claim Payment Rules

Claim processing and payment when BCN is secondary

How claims are processed and what BCN may pay when it is the second payer.

The plan that pays first reviews the claim first; BCN reviews the claim and all information about what the first plan paid when BCN is the second payer.

BCN determines payment based on whether the care received was a covered benefit and on the amount the first plan paid.

As second payer, BCN may pay remaining out-of-pocket costs left after the first plan has paid. Some providers bill BCN directly; if a member pays up front, BCN may reimburse the member or the provider for some or all expenses.

To request reimbursement, members must complete the Member Reimbursement Form available at bcbsm.com/billform.

For drug claims, members must follow BCN's authorization requirements even when BCN is the second payer.

Policy Summary

Payerblue cross blue shield - michigan

PolicyAbout Blue Care Network coordination of benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor drug claims, members must follow BCN's authorization requirements even when BCN is the secondary payer.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Key Definitions for Coordination of Benefits

inv-03: coordination of benefits — definition of the process for combining or allocating payments when a member has more than one health plan

DefinitionCoordination of benefits: The process by which BCN determines how to combine or allocate payments when a member has more than one health or prescription drug coverage source.

PurposeBCN coordinates benefits from all coverage sources (for example, spouse's plan, both parents' plans for a child, auto insurer, or workers' compensation) to lower costs while providing required coverage.

ScopeApplies when a member has more than one health care or prescription drug plan; BCN combines or allocates payments across those sources.

Member examplesSituations include coverage under a spouse's plan, a child covered by both parents' plans, or concurrent coverage with auto or workers' compensation insurers.

inv-04: who pays first — rules for primary payer determination including birthday rule and CMS guidelines for Medicare

Birthday rule for dependentsWhen a child is covered by both parents' health plans, the plan of the parent whose birthday falls earliest in the year generally pays first.

Court ordersA court order (for example, in divorce situations) overrides the birthday rule and determines which plan pays first.

Medicare coordinationIf a member has Medicare and BCN coverage, BCN follows Centers for Medicare & Medicaid Services (CMS) guidelines to determine who pays first.

OpenPayer

About Blue Care Network coordination of benefits

When Blue Care Network Is Secondary — Claim Payment Rules

Provider and Pharmacy Requirements When BCN Is Secondary

Key Definitions for Coordination of Benefits