CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coordination of Benefits (COB) Policy

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; it applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoordination of Benefits (COB) Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and authorization criteria prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 dayssecondary claim filing limit from primary insurer RA

Medicaid lastMedicaid is payer of last resort

INTEGRITY last resortINTEGRITY last resort exception

CMS standardsdocumentation standard

Coordination of Benefits — Coverage & Processing Rules

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COB coverage criteria and processing rules

Coverage and processing rules when members have multiple coverages.

Services must be medically necessary to qualify for reimbursement.

Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and clinical policy to determine medical necessity.

ALL of the following

Order specifics
- Medicaid is always the payer of last resort.
- INTEGRITY is payer of last resort except when a working INTEGRITY member also has commercial coverage and the employer group size is under 19 (INTEGRITY would be primary in that case).
- TRICARE/Champus and Medicare are primary to Medicaid; TRICARE is payer of last resort after commercial or Medicare coverage.
- For dependents covered by two parents who are not separated or divorced, the plan of the parent whose birthday (month and day) falls earlier in the calendar year is primary; if birthdays are the same, the plan that has covered the parent longest is primary.

When Neighborhood is secondary, claims must be submitted electronically with the primary carrier's remittance advice (RA) attached.

The RA must be legible and must match claim data; Neighborhood will pay secondary only for covered benefits.

Timely filing for secondary claims is 365 days from the date of the primary insurer's remittance advice (RA), unless otherwise specified by contract.365 days

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

Documentation must support services billed and medical necessity and is subject to review; Neighborhood follows CMS standards and may request medical records.

Providers must verify member eligibility, coverage and authorization criteria prior to rendering services and follow contractually defined timely filing and billing rules.

Contact Provider Services at 1-800-963-1001 for questions; billable services are subject to contractual agreements.

Coding must meet AMA CPT, ICD-10-CM, and HCPCS Level II standards.

Members may be responsible for cost sharing (coinsurance, copays, deductibles) under commercial plans; review member cost-sharing obligations prior to finalizing charges.

Provider Requirements and Submission Instructions

Prior Authorization

Verify eligibility, coverage, and authorization before services

Verify member eligibility, coverage, and any prior authorization requirements before providing services. Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for authorization criteria, and contact Provider Services at 1-800-963-1001 with questions.

Billing Rule

Submit electronic secondary claims with primary RA attached

When Neighborhood is secondary, 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. Timely filing for secondary claims is 365 days from the date of the primary carrier's RA unless a provider contract specifies otherwise.

If Neighborhood paid but later determines it was not primary, retract the payment, bill the primary insurer, then resubmit to Neighborhood with the primary insurer's EOB.
Neighborhood will only pay secondary for services that are covered benefits under the plan.

Key Definitions

Primary payer

DefinitionThe plan responsible for payment first per NAIC-based order of benefit determination; includes rules such as the birthday rule for dependents, custody/divorce rules, active employee before retiree, and longest-held plan tiebreaker.

Birthday ruleWhen 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 birthdays are the same, the plan that has covered the parent longest is primary.

Custody rule for divorced/separated parentsIf parents are divorced/separated and no court decree exists, the order is: plan of custodial parent; plan of custodial parent's spouse; plan of noncustodial parent; plan of noncustodial parent's spouse; a court decree specifying responsibility takes precedence.

Active employee ruleThe plan that covers the person as an active employee is primary before plans that cover the person as laid-off or retired.

Payer of last resort

DefinitionA plan that pays only after other applicable plans have paid; examples include Medicaid and INTEGRITY in most cases.

Medicaid statusMedicaid is always the payer of last resort and will pay after Medicare, TRICARE/Champus, and commercial coverages as applicable.

INTEGRITY statusINTEGRITY is generally payer of last resort except when an INTEGRITY member is also covered by commercial insurance and the employer group size is under 19, in which case INTEGRITY may be primary.

OpenPayer

Coordination of Benefits (COB) Policy

Coordination of Benefits — Coverage & Processing Rules

Required Coding Systems

Provider Requirements and Submission Instructions

Key Definitions

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