CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coordination of Benefits (COB)

This policy governs how Neighborhood Health Plan of Rhode Island coordinates benefits when members are covered by more than one health plan, including order of benefit determination, claim submission rules, documentation, and member cost-sharing responsibilities. It applies to Neighborhood members covered by Medicaid (excluding EFP), INTEGRITY, and commercial plans.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoordination of Benefits (COB)

Policy CodePolicy N/A

Change TypeRevised

Effective Date

Next Review Date

Key ActionProviders must verify eligibility and submit secondary claims electronically with the primary carrier's Remittance Advice attached.

SourceLink

POLICY UPDATE CHANGES

Updated limit for secondary claim submissions.

180 dayssecondary claim submission limit from date of primary RA

Medicaid lastMedicaid is payer of last resort

NAIC modelNAIC guideline

CMS standardsdocumentation standard

Coordination of Benefits Rules

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Coordination of Benefits criteria

Rules for determining which plan is primary and requirements when Neighborhood is secondary:

Order of benefit determination follows NAIC guidelines; Medicaid is payer of last resort; TRICARE is primary to Medicaid and payer of last resort after commercial or Medicare.

INTEGRITY is the payer of last resort except when an INTEGRITY member with commercial coverage is working and group size is under 19, in which case INTEGRITY may be primary.

For commercial plans: employee coverage is primary over dependent coverage.

If two or more plans cover a dependent child whose parents are not separated or divorced, the plan of the parent whose birthday (month and day) falls earlier in the calendar year is primary; if both parents have the same birthday, the plan that has covered the parent longest is primary.

If parents are divorced or separated and there is no court decree, the order is: plan covering the parent with custody, then plan covering the parent not having custody, then the custodial parent's spouse, then the non-custodial parent's spouse; a court decree specifying responsibility for health care takes precedence. If decree states joint custody, use the birthday rule.

Active employee coverage is primary over laid-off or retired coverage; when indeterminate, the plan that has covered the person longer is primary.

When Neighborhood is secondary, providers must submit claims electronically with the primary carrier's Remittance Advice (RA) attached; the RA must be legible and all charges and member information must match the claim form.

Secondary claim submission must be made within 180 days from the date of the primary insurer's Remittance Advice (RA), unless otherwise dictated by provider contract.

Neighborhood will only pay secondary for services that are covered benefits under the plan and may retract payments if it determines after payment that it was not the primary insurer.

Providers must bill in accordance with contractually determined timely filing guidelines; billable services are subject to contractual agreements.

Coding must adhere to CPT, ICD-10-CM, and HCPCS Level II standards.

Neighborhood reserves the right to request medical records to support billed services and medical necessity; documentation must follow CMS standards.

Commercial plan members have cost sharing responsibilities (coinsurance, copays, deductibles) and may incur out-of-pocket expenses based on plan selection.

This policy is informational and not a guarantee of reimbursement; payments are subject to member eligibility, claims edits, authorization policies, provider contracts, and regulations.

Accepted Coding & Submission Limits

Accepted coding systemsmixed

CPT	Coding must meet AMA CPT standards
ICD-10-CM	Diagnosis coding must meet ICD-10-CM standards
HCPCS	Procedure and supply codes must meet HCPCS Level II standards

inv-03: secondary_submission_time_limit

Secondary submission time limit180 days from date of the primary insurer's Remittance Advice (RA)

Submission format requirementClaims submitted to Neighborhood for secondary payment must be submitted electronically with the primary carrier's Remittance Advice (RA) attached

RA requirementsThe Remittance Advice must be legible and all charges and member information must match the claim form

ExceptionsUnless otherwise dictated by provider contract, the 180-day limit applies

Retracted paymentsIf Neighborhood determines after payment that it was not the primary insurer, a retraction of that claim payment may occur and the claim should be billed to the primary insurer

Provider Responsibilities & Claim Submission

Documentation Required

Provider responsibilities and secondary claim submission requirements

Providers must verify member eligibility, coverage, and authorization criteria prior to rendering services. Claims submitted to Neighborhood for secondary payment must be submitted electronically with the primary carrier’s Remittance Advice (RA) attached; the RA must be legible and all charges and member information must match the claim form. When Neighborhood is secondary, claims must be submitted within 180 days from the date of the primary insurer’s RA unless otherwise dictated by the provider contract. Neighborhood will only pay secondary for services that are covered benefits under the plan and may retract a claim payment if Neighborhood determines after payment that it was not the primary insurer. Billable services and coding must meet contractual timely filing guidelines and adhere to AMA CPT, ICD-10-CM, and HCPCS Level II coding standards.

Verify eligibility, coverage, and authorization before providing services. (See: provider responsibility statement.)
Submit secondary claims electronically with the primary carrier’s Remittance Advice (RA) attached; RA must be legible and match the claim. (See: Claim Submission.)
Submit secondary claims within 180 days of the primary carrier’s RA unless the provider contract specifies otherwise. (See: Claim Submission.)
Neighborhood only pays secondary for services that are covered under the plan and may retract payments if it is later determined Neighborhood was not primary. (See: Claim Submission.)
Ensure coding meets AMA CPT, ICD-10-CM, and HCPCS Level II standards and submit within contractually determined timely filing guidelines. (See: Claim Submission.)

Key Definitions

inv-05: Medicaid — payer of last resort

DefinitionMedicaid is the payer of last resort

ImplicationMedicare and TRICARE/Champus are primary to Medicaid

Order of benefits contextThis designation is part of Neighborhood's order of benefit determination modeled after NAIC guidelines

Related ruleTricare is the payer of last resort after commercial or Medicare coverage

inv-06: NAIC guideline — order of benefit determination modeled after NAIC guideline

Model usedOrder of benefit determination is modeled after the National Association of Insurance Commissioners (NAIC) guideline

ApplicationNeighborhood applies NAIC-based rules to determine primary versus secondary responsibility among multiple coverages

Examples includedRules reference employee vs. dependent status, birthday rule for dependent children, length of coverage when birthdays coincide

Interaction with specific plansNAIC-modeled order is applied alongside plan-specific rules (e.g., INTEGRITY, TRICARE, Medicaid) described in the policy