Medicare - Administrative Procedures |
Coordination of Benefits
Coordination of Benefits (COB) is a way of determining the order in which benefits are paid and the amounts that are payable when a member is covered under more than one group health plan.
Note: Any work-related injury is not a covered benefit. Claims are not coordinated for workers’ compensation.
Entitlement of Member
If a member is entitled to receive medical/health benefits under another group insur- ance plan, the benefits under the ConnectiCare plan will be coordinated with benefits under the other plan(s), up to 100% of the member’s responsibility. In no event shall ConnectiCare be liable for more than it would have been liable as the primary payer. The member:
• must notify ConnectiCare of other coverage and will be responsible for payment of all non-covered services; and
• shall never be liable for more than their applicable cost share (e.g., copayments, coinsurance, deductibles, etc.) under their ConnectiCare Plan.
Provider Responsibility
• You must bill the other health plan insurance/insurer first, when ConnectiCare is secondary carrier.
• When submitting a claim to ConnectiCare as secondary carrier, you must also include the Explanation of Benefits (EOB) from the other health plan.
• You must indicate the other health plan insurance on the bill you submit to ConnectiCare.
• You must submit the procedure codes which are required per your contract with ConnectiCare. If you submit procedure codes which are not on your contract/fee schedule, the claim will be denied.
Effect on Payment
• ConnectiCare as Primary Carrier: ConnectiCare will pay the full contracted, allowable amount minus applicable cost-sharing or adjustments. (The patient may receive reimbursement from the secondary carrier for any out-of-pocket expenses incurred, such as the copayments, coinsurance and deductibles.)
• ConnectiCare as Secondary Carrier:
• Payment will not be made until we receive a copy of the Explanation of Benefits (EOB) indicating the amount paid by the primary carrier.
• ConnectiCare will pay up to the member’s responsibility under the primary carrier or ConnectiCare’s contracted amount, which ever is lower.
• We recommend that the copayment not be collected at the time of service. Once you receive payment from all carriers, determine if there is any remaining billable balance. Most balance billing occurs when the member has a deductible that needs to be satisfied, such as a Medicare Part B deductible, or a commercial carrier deductible.
• The filing limit for claims where ConnectiCare is secondary is 180 days after the issue date of the last EOB received from the primary carrier. Claims denied as beyond the filing limit by the primary carrier will not be accepted for payment by ConnectiCare.
Note: If the member has medical coverage under their auto carrier, the auto carrier would be primary for claims related to the auto accident, up to the policy maximum.
• Dual ConnectiCare Coverage: ConnectiCare will coordinate benefits under the sec- ondary plan, after the first ConnectiCare plan has paid. For example, under the first ConnectiCare plan the patient is responsible for a copayment and under the second plan, that copayment and/or any applicable balance will be paid, providing policy limitations/guidelines are followed. You should not take the primary copayment up front since this amount will be paid to you under the secondary plan, otherwise, you will be responsible for reimbursing the member once the secondary payment is made.
Order of Benefit Determination
Following are some generally applicable rules for determining which plan is primary or secondary. If you have any questions after reading this manual, please contact Provider Services at 1-877-224-8230.
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Member with commercial plan |
Primary Carrier
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Subscriber
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ConnectiCare
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Subscriber’s spouse without other group health insurance
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ConnectiCare
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Subscriber’s spouse with other carrier group health insurance
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Other
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Dependent child when both parents have insurance, and are not separated or divorced |
Determined by the COB Birthday Rule* (unless the Gender Rule** applies)
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Member with commercial plan
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Primary Carrier
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Child whose parents are divorced, legally separated, or whose health coverage
has been ordered by the courts.
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Health plan/insurer of the parent whom the court has care ordered to provide
coverage for the child.
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Child whose parents are divorced or legally separated. Parent
with custody is not remarried.
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Insurer of parent with legal custody
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Child whose parents are divorced or legally separated. Parent
with legal custody is remarried.
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Four (4) levels of COB:
• first, the plan of the parent custody
• second, the plan of the spouse of the parent with custody
• third, the plan of the parent without custody
• plan of the spouse of the parent without
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Member with Medicare
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Primary Carrier
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Active employee is 65 or older and if the group he/she works for has fewer
than 20 employees
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Medicare
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Retired employee is eligible for Medicare and has Medicare Part A & B
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Medicare
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Member with Medicare Carrier
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Primary Carrier
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Individual entitled to Medicare due to End Stage Renal Disease (ESRD)
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First 30 months ConnectiCare commercial plan, then Medicare.
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Retired spouse of active employee has own retiree policy through previous
employer and has Medicare Parts A & B.
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ConnectiCare commercial plan is primary, Medicare is secondary, the retiree
policy is tertiary
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Spouse of active employee is under 65 and eligible for Medicare due to total
disability.
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ConnectiCare commercial plan is primary (as long as the Employer group has
over 100 employees); Medicare is primary if the employer has less than 100
employees
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Spouse (over 65) of active employee who is under 65
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ConnectiCare commercial plan is primary and Medicare is secondary
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* Birthday Rule: Primary carrier is the health plan/insurer of the parent whose month and day of
birth occurs earlier in the calendar year. If parents share the same birthday, the primary carrier is
the health plan that has been in effect longer.
**Gender Rule: For dependent children covered by each parent’s policy when the parents are not divorced
or separated, the plan of the father is primary over the mother’s plan.
Note: Pursuant to Connecticut COB rules and federal law, ConnectiCare does not coordinate benefits under
a ConnectiCare® SOLO individual plan with other group plans or other individual plans. If a
ConnectiCare® SOLO member is also enrolled in a Medicare plan, Medicare will be the primary plan.
