CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Coordination of Benefits (COB)

Governs how Neighborhood Health Plan of Rhode Island coordinates benefits when members have more than one health plan, including order of benefit determination, claims submission when Neighborhood is secondary, documentation, and member cost-sharing responsibilities. Applies to Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCoordination of Benefits (COB)

Policy CodePolicy N/A

Change TypeNo material changes

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 at 1-800-963-1001.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 dayssecondary claim filing limit from primary RA

Medicaid last resortMedicaid is payer of last resort

3Applies to lines

12/11/2024policy create date

Coordination of Benefits Rules

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Coordination of Benefits criteria

Covered when the following rules for order of benefit determination, claims handling when Neighborhood is secondary, documentation, and member responsibility are met:

Order of benefit determination follows NAIC guidelines as modeled by Neighborhood Health Plan of Rhode Island.

Medicaid is the 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; in that case INTEGRITY is primary.

When two plans cover a dependent child of 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 both parents have the same birthday, the plan that has covered the parent longest is primary.

For divorced or separated parents without a court decree, the order for a dependent is: (1) plan of the parent with custody; (2) plan of the custodial parent's spouse; (3) plan of the noncustodial parent; (4) plan of the noncustodial parent's spouse. A specific court decree naming responsibility overrides these rules; if the decree provides joint custody, use the birthday rule.

A plan that covers a person as an active employee is determined before plans that cover the person as laid-off or retired; if none of the rules apply, the plan which has covered the person longer is primary.

If Neighborhood paid but is not primary, Neighborhood may retract payment; provider should bill the primary insurer and then resubmit to Neighborhood for secondary coverage with the primary carrier's EOB/Remittance Advice (RA) attached. Secondary claims must be submitted electronically with the primary carrier's RA legible and attached, and charges and member information must match the claim form.

Resubmissions should include the primary insurer's EOB/RA to document primary payment.

Timely filing when Neighborhood is secondary: 365 days from the date of the primary insurer's remittance advice (RA) for participating and nonparticipating providers, unless the provider contract specifies otherwise.

Neighborhood will only pay as secondary for services that are covered benefits under the member's plan.

Neighborhood may request medical records for any service billed; documentation must support the billed services and medical necessity and follows CMS documentation standards.

Members may be responsible for cost sharing (coinsurance, copays, deductibles) according to their commercial plan selection; members should review cost-sharing obligations or contact Member Services prior to finalizing charges.

Required Coding and Timely Filing

Required coding systemsmixed

CPT	Coding must meet AMA CPT standards
ICD-10-CM	Diagnosis coding must meet ICD-10-CM standards
HCPCS	Procedure/material coding must meet HCPCS Level II standards

Timely filing for secondary claims

Timely filing window365 days from the date of the primary insurer's Remittance Advice (RA) for participating and nonparticipating providers

Condition for exceptionUnless otherwise dictated by the provider contract (contractual timely filing guidelines may supersede)

Submission requirementSecondary claims must be submitted electronically to Neighborhood with the primary carrier's RA attached and legible

Matching informationAll charges and member information on the secondary claim must match the claim form and the primary RA

Provider Responsibilities

Prior Authorization

Pre-service verification of eligibility, coverage, and authorizations

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

Verify member eligibility and coverage prior to service.
Confirm whether prior authorization is required using the Prior Authorization Reference page and Clinical Medical Policies.
If unclear, contact Provider Services at 1-800-963-1001 before providing services.

Key Definitions and Rules

Medicaid as payer of last resort

Payer of last resort ruleMedicaid is always the payer of last resort

Primary to MedicaidMedicare and TRICARE/CHAMPUS are primary to Medicaid

NAIC guidanceNeighborhood's order of benefit determination is modeled after NAIC guidelines

Birthday rule

Birthday rule (dependents)When two plans cover a dependent child of parents not separated, the plan of the parent whose birthday (month and day) falls earlier in the calendar year is primary

Tie-breaker if same birthdayIf both parents have the same birthday, the plan that has covered the parent longest is primary

Applicable scenarioApplies to dependents of parents who are not separated or divorced (see divorced/separated rules for other situations)