Rules determining primary versus secondary payer and claim submission requirements.
Neighborhood follows NAIC-modeled order of benefit determination; specific rules apply for Medicaid, Medicare, TRICARE/Champus, INTEGRITY for Duals, and commercial plans.
Medicaid is the payer of last resort; Medicare and TRICARE/Champus are primary to Medicaid. INTEGRITY for Duals is payer of last resort except when a working INTEGRITY for Duals member also has commercial coverage and the group size is under 19 (INTEGRITY for Duals would be primary in that case). Tricare is payer of last resort after commercial or Medicare coverage.
If a member is covered as an active employee by one plan and as a dependent, laid-off, or retired person by another, the plan covering the person as an active employee is primary. If none of the rules determine order, the plan that has covered the person longest is primary.
Dependent children - birthday rule: When 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 only) 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.
Divorced/separated parents: When parents are divorced or separated and there is no court decree, the order of benefits for a dependent child is: (1) plan covering the custodial parent; (2) plan covering the custodial parent's spouse; (3) plan covering the noncustodial parent; (4) plan covering the noncustodial parent's spouse. A court decree specifying responsibility for health care supersedes these rules. If the decree provides joint custody, use the birthday rule.
Secondary claim handling: If Neighborhood paid but is later determined not to be primary, Neighborhood may retract payment; the claim must be billed to the primary insurer and then resubmitted to Neighborhood with the primary insurer's Explanation of Benefits (EOB)/Remittance Advice (RA) for secondary consideration. Neighborhood will only pay secondary for services that are covered benefits under the plan.
Electronic submission & documentation: 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. Neighborhood may request medical records to support billed services and medical necessity, and documentation must support the services billed.
Timely filing for secondary: When Neighborhood is the secondary insurer, the filing limit for secondary claim submission is 180 days from the date of the primary insurer's remittance advice (RA), unless otherwise dictated by the provider contract.
Coding standards: Coding must meet AMA CPT, ICD-10-CM, and HCPCS Level II standards per applicable coding guidelines.
CONNECT (Coordination-only D-SNP) specifics: For Neighborhood CONNECT (Coordination-only D-SNP), providers submit claims to Neighborhood and any remaining copays/coinsurance amounts and Medicaid-covered benefits must be submitted to EOHHS for reimbursement.