CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coordination of Benefits (COB) payment policy

Governs how Neighborhood Health Plan of Rhode Island coordinates benefits when members have multiple health plans, including order of benefit determination, claim submission rules, documentation, and member cost-sharing; applies to Medicaid (excluding EFP), INTEGRITY, and Commercial members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoordination of Benefits (COB) payment policy

Policy CodePolicy N/A

Change TypeRevised filing limit for secondary submissions

Effective DateN/A

Next Review DateN/A

Key ActionVerify eligibility, coverage and authorization criteria prior to rendering services; refer to plan-specific Prior Authorization Reference and contact Provider Services with questions.

SourceLink

POLICY UPDATE CHANGES

Updated filing limit for secondary submissions to 180 days from the date of the primary insurer's remittance advice (RA).

180 dayssecondary claim filing limit from primary RA

Medicaid, INTEGRITY, Commercialplans this policy applies to

NAIC-modeledorder of benefit determination standard

Member cost sharingcommercial plans may include coinsurance/copays/deductibles

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Coordination of Benefits Rules

COB criteria and operational rules

Applicable rules for determining primary vs secondary payer, claim submission requirements, timely filing, retraction/resubmission, and documentation.

Follow the NAIC-modeled order of benefit determination rules as described by Neighborhood; apply employee-before-dependent, birthday rule for non-divorced parents, special rules for divorced/separated parents (custodial parent first, then custodial parent's spouse, then noncustodial parent, then noncustodial parent's spouse), active employee before retired, and longest-covered if none of the other rules apply.

Payer hierarchy rules: Medicaid is always payer of last resort; Medicare and TRICARE/Champus are primary to Medicaid; INTEGRITY is payer of last resort except when a working INTEGRITY member also has commercial coverage and the group size is under 19; TRICARE is payer of last resort after commercial or Medicare coverage.

Secondary claim submission requirements: If Neighborhood is secondary, claims 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 will only pay secondary for services that are covered benefits under the plan.

Timely filing for secondary claims: When Neighborhood is the secondary insurer, the filing limit for claim submission is 180 days from the date of the primary insurer's remittance advice (RA), unless otherwise dictated by provider contract.

Retraction and resubmission: If Neighborhood determines after payment that it is not the primary insurer, Neighborhood may retract that claim payment; the claim should be billed to the primary insurer and then resubmitted to Neighborhood with the primary insurer's EOB for secondary consideration.

Documentation requirements: Neighborhood may request medical records for any billed service; medical record documentation must support the services billed and the medical necessity of those services and follows CMS standards for documentation.

Coverage limitations and contractual considerations: Payments as secondary are subject to member eligibility, provider contractual agreements, coding standards (CPT, ICD-10-CM, HCPCS Level II), prior authorization and applicable regulations; billable services remain subject to contractually determined timely filing guidelines.

Required Coding Systems and Filing Limits

Required coding systemsmixed

CPT	Coding must follow AMA CPT Editorial Panel codebook
ICD-10-CM	Diagnosis coding must follow ICD-10-CM
HCPCS	Procedure and supply codes must follow HCPCS Level II

Timely filing for secondary claims

Filing timeframeSecondary claims must be submitted within 180 days from the date of the primary insurer's Remittance Advice (RA), unless a provider contract specifies a different limit.

Submission formatClaims submitted to Neighborhood for secondary payment must be submitted electronically with the primary carrier's RA attached.

RA requirementsThe primary carrier's RA must be legible and all charges and member information must match the claim form.

Coverage conditionNeighborhood will only pay as secondary for services that are covered benefits under the plan.

Contractual timely filingProviders are required to submit complete claims within contractually determined timely filing guidelines when contract terms apply.

Provider Responsibilities

Prior Authorization

Verify eligibility, coverage, and prior authorization before rendering services

It is the provider's responsibility to verify member eligibility, coverage and any required prior authorization before rendering services; refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Verify eligibility and coverage prior to service.
Obtain any required prior authorization per the plan-specific Prior Authorization Reference.
Refer to Neighborhood's Clinical Medical Policies for medical necessity criteria.
Contact Provider Services at 1-800-963-1001 for assistance.

Key Definitions

Order of benefit determination & payer-of-last-resort rules

NAIC-modeled orderNeighborhood uses an order of benefit determination modeled after the National Association of Insurance Commissioners (NAIC).

Medicaid as last resortMedicaid is always the payer of last resort; Medicare and TRICARE/Champus are primary to Medicaid.

INTEGRITY payer-of-last-resort ruleINTEGRITY is payer of last resort except a working INTEGRITY member with commercial coverage — INTEGRITY is primary if the group size is under 19.

TRICARE hierarchyTRICARE is the payer of last resort after commercial or Medicare coverage.

Payer of last resort — Medicaid and INTEGRITY

Medicaid payer-of-last-resortMedicaid is always the payer of last resort (Neighborhood treats Medicare and TRICARE as primary to Medicaid).