Currentcare_continuumPolicy n05736

Coordination of Benefits

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This reimbursement policy governs how Network Health (Care Continuum) determines the order of payment and processes claims when a member has coverage under more than one plan; it applies to all lines of business and affects members, providers, and payers interacting with Network Health.

Policy Summary

Payercare_continuum

PolicyCoordination of Benefits

Policy CodePolicy n05736

Change TypeNo material changes

Effective DateApr 1, 2011

Last ReviewJun 1, 2027

Next Review DateJun 1, 2027

Key ActionObtain prior authorization for services when Network Health is secondary to help ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 dayssecondary payer timely filing for participating providers

365 dayssecondary payer timely filing for non-participating providers (Medicare)

All linespolicy scope

Generally secondaryMedicare coordination stance

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Currentcare_continuumPolicy n05736

Coordination of Benefits

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Sign up for care_continuum Policy n05736 alerts

Get alerted when Policy n05736 changes without checking for updates manually.

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Policy Summary

Payercare_continuum

PolicyCoordination of Benefits

Policy CodePolicy n05736

Change TypeNo material changes

Effective DateApr 1, 2011

Last ReviewJun 1, 2027

Next Review DateJun 1, 2027

Key ActionObtain prior authorization for services when Network Health is secondary to help ensure coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 dayssecondary payer timely filing for participating providers

365 dayssecondary payer timely filing for non-participating providers (Medicare)

All linespolicy scope

Generally secondaryMedicare coordination stance

Order of Benefit Determination

Rules to determine primary vs secondary plan:

ALL of the following

No COB Provision: If the member's other group health plan does not have a COB provision, that plan will be primary.
Subscriber vs Dependent: A subscriber's plan is primary over a plan that covers that subscriber as a dependent.
Dependent children - Birthday Rule: For a dependent child covered by both parents, the plan of the parent whose birth date occurs earlier in the calendar year is primary; if both parents share the same birth date, the plan that has covered the parent for a longer period of time is primary.
Dependent children of unmarried/separated/divorced parents: When a court decree awards custody, the plan of the parent with custody is primary. If joint custody is specified without assignment of responsibility for health care expenses, the Birthday Rule applies. Order if decree does not specify: (1) plan of parent with custody; (2) plan of spouse of parent with custody; (3) plan of parent without custody; (4) plan of spouse without custody.
Active vs Inactive employee: If a spouse is laid off or retired, the plan covering an actively-at-work spouse is primary for the inactive spouse and their dependents. Continuation of coverage is secondary to active work coverage.
Fallback - longer coverage: If none of the rules determine order, the plan that has covered the person for a longer period of time will be primary.
COB with Medicare: Coordination with Medicare conforms to Federal Statutes and Regulations. Network Health is generally secondary to Medicare; if a member is eligible for Medicare but not enrolled, Network Health will coordinate as if they were covered by Medicare.
Effect on benefits when Network Health is secondary: When another plan is primary, Network Health will reduce benefits so that combined payments do not exceed allowable expenses and will not reimburse charges denied because a provider failed to follow the primary plan's procedures.
Member obligations - timely filing: Members must incur allowable expenses while enrolled with Network Health and submit claims within applicable timely-filing limits when Network Health is secondary (claims must be submitted within 90 days of the primary plan remittance for commercial/participating providers; Medicare/non-participating timelines may apply).

Billing & Timely Filing Requirements

Billing limitsmixed

No codes listed

Timely filing when secondary (commercial/participating)

Filing deadline (participating/commercial)Claims must be submitted within 90 days of the payment date listed on the primary payer's remittance advice, or as specified in the provider contract.

Eligibility windowMember must incur allowable expenses while enrolled with Network Health to be eligible for secondary consideration.

Contract exceptionsProvider contract terms may specify a different timely-filing period; in such cases, the contract timeframe applies.

Effect of primary denialNetwork Health will not reimburse charges denied because the provider failed to follow the primary plan's procedures.

Timely filing when secondary (Medicare non-participating)

Filing deadline (non‑participating/Medicare)

Provider Responsibilities

Prior Authorization

Prior authorization recommended when Network Health is secondary

Obtain prior authorization for services when Network Health is the secondary payer to help ensure coverage if the primary plan denies the claim; Network Health's prior authorization, coverage, and criteria requirements apply regardless of primary/secondary status.

Prior authorization helps confirm coverage because Network Health cannot predict how the primary plan will process the claim.
Network Health’s prior authorization, coverage, and criteria requirements apply whether it is primary or secondary.

Key Definitions

Allowable Expense

DefinitionAn allowable expense is a Medically Necessary health care service or product for which a Member is eligible, as determined by Network, to receive benefits pursuant to the terms of the Member's Health Plan.

Timing requirementMember must incur the allowable expense while enrolled with Network Health for it to be eligible for payment.

Benefit coordinationNetwork Health will reduce benefits when another plan is primary so that total payments do not exceed total allowable expenses.

Coverage Document

DefinitionA coverage document is a written document that describes the benefits, services, exclusions, limitations and conditions that are available for or applicable to coverage under the Plan.

Governing provisions