Currentharvard pilgrim health carePolicy N/A

Coordination of Benefits (COB) Claims

Governs how Harvard Pilgrim processes coordination of benefits claims (including rules for primary/secondary payer determination, filing deadlines, special state rules, and submission addresses) for members except those in Choice or Choice Plus via Passport Connect. Affects providers and members when multiple coverages exist.

Policy Summary

Payerharvard pilgrim health care

PolicyCoordination of Benefits (COB) Claims

Policy CodePolicy N/A

Change TypeNon‑material removal

Effective DateN/A

Next Review DateN/A

Key ActionFollow Harvard Pilgrim procedures for referral, notification, and prior authorization when Harvard Pilgrim is secondary.

SourceLink

POLICY UPDATE CHANGES

Removed Connecticut Retroactive Denial section.

90 daysStandard filing limit for COB claims (secondary carrier)

120 daysMaine filing limit when Harvard Pilgrim is secondary

180 daysNew Hampshire filing limit for retroactive primary denials

Birthday RuleDependent primary payer determination

COB P.O. BoxesClaims & correspondence addresses

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.

Coordination of Benefits Determination & Filing Rules

COB determination and filing criteria

Rules used to determine primary versus secondary payer and requirements for claim submission.

Dependent primary payer - Birthday Rule: When both parents have family coverage under different plans, the primary carrier for dependents is the plan of the parent whose birthday falls nearest to January 1 in the calendar year.

Custody/Court Order Exception: A divorce decree, child custody determination or court order may override the Birthday Rule; Harvard Pilgrim will process claims per the court order or decree.

Standard Filing Limit (Harvard Pilgrim secondary)

Claims must be received by Harvard Pilgrim within 90 days of the date on the primary carrier's Explanation of Benefits (EOB).
Claims submitted beyond the 90-day filing limit or without a copy of the primary carrier's Explanation of Payment/Benefits (EOP/EOB) will be denied.

Maine filing variation (Harvard Pilgrim secondary): In Maine, claims must be submitted within 120 days from the date the primary insurer processed the claim or retroactively denied a previously paid claim (date shown on the primary insurer's EOB).

New Hampshire retroactive termination variation (Harvard Pilgrim secondary)

When the primary carrier has retroactively terminated a policy, claims must be submitted within 180 days from the date the primary insurer retroactively denied a previously paid claim (date shown on the primary insurer's EOB).
This 180‑day rule does not apply if the primary carrier terminated under normal (non‑retroactive) circumstances.

Dental COB determination

Harvard Pilgrim uses a procedure‑based model for dental claims: covered oral surgery benefits — Harvard Pilgrim is primary.
Preventive and pediatric preventive dental benefits — dental carrier is primary.

Medicare coordination rules

Primary/secondary status depends on member age, employment status, and employer size per CMS rules.
Employer size thresholds affect determination (notably 20 and 100 employee thresholds as specified in CMS guidance).
For members with Medicare due to end‑stage renal disease (ESRD), contact Harvard Pilgrim Insurance Liability and Recovery Specialist for determination (888‑888‑4742, ext. 38999).

Payment and documentation requirements

When Harvard Pilgrim is secondary, the primary insurer's EOP/EOB must match the date of service, member name, and charged amount for the claim to be processed.
No balance billing to Harvard Pilgrim or members when Harvard Pilgrim is primary or secondary per policy; if other insurance is later identified, Insurance Liability Recovery (ILR) may recover or adjust payments.
Providers must follow Harvard Pilgrim policies and procedures related to referral, notification, prior authorization and prior approval when Harvard Pilgrim is secondary.

Coding & Medicare Coordination Details

Dental COB rulesmixed

Procedure-based model for determining primary payer on dental claims (oral surgery = Harvard Pilgrim primary; preventive/pediatric preventive = dental carrier primary).

Employer size thresholds for Medicare coordination

Employer size thresholdsAge and employment status rules use employer-size thresholds of 20 and 100 employees to determine whether Medicare or Harvard Pilgrim is primary or secondary.

20-employee threshold (Age 65+, actively working)If subscriber is age 65+ and actively working and employer has >= 20 employees, Harvard Pilgrim is primary (Medicare secondary). If employer has < 20 employees, Medicare is primary.

100-employee threshold (Under age 65, actively working)If subscriber is under 65 and actively working and employer has >= 100 employees, Harvard Pilgrim is primary (Medicare secondary). If employer has < 100 employees, Medicare is primary.

Not actively working (Under 65)If subscriber is under 65 and not actively working and employer has < 100 employees, Medicare is primary and Harvard Pilgrim is secondary.

Retirement impact (Age 65+)If subscriber is age 65+ and retired, Medicare is primary from date of retirement and Harvard Pilgrim is secondary.

Provider Requirements and Recovery Processes

Prior Authorization

Prior authorization and prior approvals required when Harvard Pilgrim is secondary

Follow Harvard Pilgrim policies and procedures related to referral, notification, prior authorization and prior approval for reimbursement when Harvard Pilgrim is secondary. Claims are paid according to Harvard Pilgrim's payment policies and procedures, and no balance bill can be submitted to Harvard Pilgrim or its members. When Harvard Pilgrim is secondary, the primary insurer's EOP must have date of service, member name, and charged amount that match the claim or the claim will be denied for incorrect EOP.

Adhere to referral, notification, prior authorization and prior approval requirements before submitting secondary claims.
Ensure the primary insurer's EOP matches date of service, member name, and charged amount to avoid denial for incorrect EOP.
Do not balance bill Harvard Pilgrim or its members.

Denial Risk

Insurance Liability Recovery (ILR) will determine primary payer and adjust claims

Terms & Filing Limits

Birthday Rule

Birthday Rule definitionWhen both parents have family coverage under two different health plans, the primary carrier for dependents is the insurance of the parent whose birthday falls nearest to January 1 in the calendar year.

Example (mother Feb 23; father Nov 12)Mother's plan is primary because her birthday (Feb 23) is nearer to January 1 than the father's (Nov 12).

Override conditionsA divorce decree, child custody order, or court order may override the Birthday Rule (see exceptions).

Filing limits and state variations

Standard filing limitClaims submitted when Harvard Pilgrim is secondary must be received within 90 days of the date on the primary carrier's Explanation of Benefits (EOB).

Maine variation