CurrentHealth-New-EnglandPolicy N/A

Coordination of Benefits and Subrogation

This document governs Health New England's rules and procedures for coordinating benefits when members have multiple coverages and for pursuing subrogation against third parties; it affects HNE members, providers submitting claims, and other insurers/third parties.

Policy Summary

PayerHealth-New-England

PolicyCoordination of Benefits and Subrogation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionIf HNE is secondary, providers must bill the primary insurer first and submit the claim to HNE with the explanation of payment or denial within 90 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystimeframe to submit explanation of payment/denial to HNE

800-842-4464COB/Subrogation contact (providers)

ends with *01indicates HNE subscriber

PPACA rulesMedicare timely-filing reference

Coverage Determination Rules

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Coverage determination rules

Covered when the following coordination-of-benefits rules apply; providers should follow HNE prior-approval rules even when HNE is secondary.

ALL of the following

The plan that covers the person as an employee (subscriber) is primary; HNE subscribers (member number ending with *01) have HNE as the primary insurer and any coverage carried by a spouse is secondary.
If the spouse of an HNE member has employer coverage, that insurance is primary for the spouse and HNE is secondary.
If a person is a subscriber under two plans, the plan that has covered the person longest is primary.
For dependent children of non-divorced parents, the birthday rule applies: the plan of the parent whose birthday falls earlier in the calendar year is primary; if both parents share the same birthday, the plan that has covered the parent longest is primary.

For dependents of divorced parents, order of payment is: (1) plan of parent responsible by court decree; (2) plan of parent with custody; (3) plan of the spouse of the custodial parent; (4) plan of the noncustodial parent.

Auto/Third-Party Liability: When an HNE member is involved in an auto accident or a third party is liable, the auto insurer (including PIP) is primary. Providers should submit outstanding medical claims with a copy of the third party Explanation of Payment (EOP) and third-party insurance information to HNE within 90 days after PIP is exhausted or the auto claim is denied.

Workers' Compensation is legally primary for work-related injuries; HNE does not cover services that are the legal liability of Workers' Compensation. If Workers' Compensation denies coverage, providers may submit claims to HNE with the Workers' Compensation denial within 90 days.

Medicare primary/secondary status follows federal law; if Medicare is primary, submit to Medicare first and then bill HNE with the Medicare EOP within 90 days. Timely-filing rules for Medicare vary by date of service per PPACA and pre-PPACA rules.

Providers must follow HNE prior approval/guideline rules even when HNE is secondary.

Providers who are aware of third-party liability or need coordination should contact HNE COB/Subrogation staff at (800) 842-4464 and provide pertinent information (e.g., date of accident, carrier, claim number, adjuster).

Members cannot be billed for anything other than their deductible, coinsurance, or copay regardless of whether HNE is primary or secondary.

HNE may pay covered bills and then pursue subrogation/recovery from third parties; recovered funds are applied to HNE's health service fund per policy.

Coding and Timely Filing

Not specifiedmixed

No codes listed

Medicare timely filing

Timely filing windowVaries by date of service per PPACA and pre-PPACA rules: pre-10/1/2009 follow pre-PPACA rules; 10/1/2009–12/31/2009 must be submitted by 12/31/2010; on/after 1/1/2010 must be submitted within one calendar year of service.

Required documentationWhen Medicare is primary, submit Medicare Explanation of Payment (EOP) with the claim to HNE as secondary.

Submission timeframe to HNEClaim and Medicare EOP must be submitted to Health New England Claims Department within 90 days.

Provider assistanceIf unsure whether Medicare or HNE is primary, providers should call HNE COB staff at 800-842-4464.

Provider Billing Sequence and Timing

Billing Rule

Bill primary first; submit EOP to HNE within 90 days

If HNE is secondary, bill the primary insurer first and submit the claim to HNE's Claims Department with an explanation of payment or denial within 90 days. Providers must follow HNE prior approval guidelines even when HNE is secondary.

Do not submit to HNE until the primary insurer has processed the claim.
If HNE determines another insurer is primary and a claim was submitted to HNE first, HNE will deny payment and notify the provider of the reason.
For questions, contact HNE COB staff at 800-842-4464.

Key Definitions

Coordination of Benefits (COB)

DefinitionCoordination of Benefits (COB) occurs when HNE arranges for payment from an alternative insurance which may be primary or secondary for the claim.

PurposeCOB rules determine which health plan is primary (pays first) and which is secondary (pays second) according to Massachusetts Division of Insurance rules.

Subscriber primary ruleThe plan that covers the person as an employee (subscriber) is primary; HNE subscribers (member number ending with *01) have HNE as primary.

Provider billing requirementIf HNE is secondary, providers must bill the primary insurer first and submit EOP/denial to HNE within 90 days.

Subrogation

DefinitionSubrogation occurs when HNE assumes a member's right to recover from a third party who caused the member's injury or illness.

HNE rightsHNE may make a claim against the third party and, based on state or ERISA law, place a legal hold or 'lien' on any court judgment or settlement to recover payments.

Use of recovered fundsFunds collected from third-party payers are added to the HNE health service fund to fund provider reimbursement and return of withhold.

Provider notificationIf providers are aware of third-party liability, they should notify HNE COB/Subrogation staff at 800-842-4464.

Birthday rule

Rule for non-divorced parentsFor dependent children of non-divorced parents, the plan of the parent whose birthday falls earlier in the calendar year is primary (month and day only).

Tie-breakerIf both parents share the same birthday, the plan that has covered the parent longest is primary.

Applicability'Birthday' refers only to month and day in a calendar year, not the year of birth.