Content Overview
- Adverse Determination
- Annual Limits
- Case Manager
- Certificate of Creditable Coverage
- Coordination Of Benefits
- Co-Insurance
- Co-Pay
- Covered Charges
- Department Of Insurance
- Deductible
- Eligibility
- Experimental Treatment
- Explanation Of Benefits
- Extensions
- Fee-For-Service (Indemnity)
- Formulary
- Lifetime Limits
- HMO
- Medical Necessity (Medically Necessary)
- Out Of Network
- Out-of-Pocket Maximum (also known as "Stop Loss" or "Cap")
- Palliative Care
- POS
- PPO
- Renewability
- Pre-Existing Health Condition
- Stop Clause (also known as "Stop Loss Clause")
- Underwriting (What It Is And How It Works)
- U.S. Department Of Labor
- Usual, Customary and Reasonable "(UCR")
- Utilization Management
Glossary of Health Insurance Terms To Know
Coordination Of Benefits
Next » « Previous6/32
Coordination of Benefits provisions eliminate the potential for insureds to obtain reimbursement for medical expenses from more than one insurer when there is more than one health insurance coverage. Without coordination of benefit provisions, an insured could obtain reimbursement for more than 100% of the cost of a medical service.
Industry practice with respect to Coordination of Benefits also helps determine which insurer pays first, and in what amount.
The specifics of how more than one coverage is handled between insurance companies is not generally relevant to the insured because the insured submits the claim to both companies. It is then up to the companies to figure out which one pays how much. However, to give you an idea of how Coordination of Benefits works, the sequence starts as follows:
- The plan which covers the individual as an employee pays first.
- The plan covering the individual as a dependent covers second.
- If both plans cover the individual as a dependent, the plan of the employee whose birthday occurs soonest in the year pays first. This rule ("the birthday rule") applies only if both plans have adopted the birthday rule. If either plan has not adopted the birthday rule, the plan of the male parent will pay first.
Some employers use an alternative Coordination of Benefits system called Maintenance Of Benefit.
To learn more about how Coordination of Benefits works, click here. Note that Medicare has its own rules with respect to coordination of benefits. To learn about the Medicare rules, click here. To learn how to file a claim when there is more than one coverage, click here.
Please share how this information is useful to you. 0 Comments
Post a Comment Have something to add to this topic? Contact Us.