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Coordination of Benefits (COB) rules allow medical care
plans to coordinate benefits when you are covered by more
than on group medical care plan.
COB
ensures that the level of payment, when added to the benefits
payable under another group plan, will cover up to 100%
of the eligible expenses as determined between the carriers
but will not exceed the actual cost approved for your care.
How COB Works
If you are covered by more than one group plan, COB
guidelines determine which carrier pays for covered services
first.
- The
plan that pays first is your primary plan. This plan must provide
you with the maximum benefits available to you under the plan.
- The
plan that pays second is your secondary plan. This plan provides
payments toward the balance of the cost of covered services, up to the
total allowable amount determined by the carriers.
Guidelines to Determine Primary and Secondary Plans
The guidelines below apply except for certain situations in which a faculty
or staff member has retired or been laid off. Then special rules apply.
- If a group
medical care plan does not have a Coordination of Benefits provision,
that plan is primary.
- The plan
that covers the patient as the faculty or staff member (member or subscriber)
is primary and pays before a plan that covers the patient s a dependent.
- If a child is
covered under both the mother's and father's plans, the plan of the parent (or
legal guardian) whose birthday is earlier in the year is the primary plan.
- For children
of divorced or separated parents, benefits are determined in the following
order unless a court order places financial responsibility on one parent:
- plan
of the custodial parent;
- plan
of the custodial parent's new spouse (if remarried);
- plan
of the noncustodial parent;
- plan
of the noncustodial parent's new spouse (if remarried).
If the primary
plan cannot be determined by using the guidelines above, then the plan
covering the child the longest is primary.
Subrogation
In certain cases, another person, insurance company, or organization may
be legally obligated to pay for medical care services that your medical
care plan has paid. When this happens:
- Your right
to recover payment from them is transferred to your medical care plan.
- You are
required to do whatever is necessary to help your medical care plan enforce
its right of recovery.
- If you
receive money through a lawsuit, settlement, or other means for services
paid under your coverage, you must reimburse your medical care plan.
However, this does not apply if the funds you receive are from additional
coverage you purchased in your name from another medical care company.
Filing COB Claims
Any claims payable to a primary heath insurance, the University's Worker's
Compensation plan, Medicare, or any other public agency are to be submitted
first to these groups for payment, then to the medical care plan. The medical
care plan will coordinate payment with those groups.
The amount payable under this plan will take into account any coverage
that the faculty or staff member or the dependent has under any other
employment-connected plan.
Benefits will be coordinated to provide maximum reimbursement for expenses
covered under either plan without providing for duplicate payments.
Coordination of Benefits will be consistent with medical care and insurance
industry guiding principles and state laws.
- Always
submit claims to your primary plan first.
- Keep copies
of all forms and receipts for your own files.
- When you
submit claims to your medical care plan:
- Ask
your medical care provider for an itemized receipt or a detailed
description of the services, including charges for each service.
- If
you made any payments for the service, provide a copy of the receipt
you received from the provider.
- Follow
the filing instructions provided by your benefit plan.
Right to Receive and Release Needed Information
It may be necessary for information to be obtained or released in order
to coordinate benefit payments with other plans. This can be from or to
any other medical care provider or company, organization, or person, without
your notice or consent.
Any person claiming benefits must furnish any information needed to coordinate
benefit payments.
Right to Recovery
Medical care and insurance plans generally have the right to recoup any
excess amount that may have been paid over that called for by their plan
-- from the person for whom the payments were made, or from any insurance
company or organization.
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