Coordination of Benefits. The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, and the Member does not know which is the primary plan, the Member or the Member’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Member contacts is responsible for working with the other plan to determine which is primary and will let the Member know within 30 calendar days. All health plans have timely claim filing requirements. If the Member or the Member’s provider fails to submit the Member’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Member experiences delays in the processing of the claim by the primary health plan, the Member or the Member’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier.
Coordination of Benefits. The Public Employee Benefits Board (PEBB) may adopt any of the effect-on-benefit alternatives described in the National Association of Insurance Commissioners (NAIC) 1985 model acts and regulations, or any subsequent alternatives promulgated by the NAIC.
Coordination of Benefits. In the event a member is covered under another plan or policy which provides coverage, benefits or services (plan) that are covered benefits under this dental plan, then the benefits of this plan shall be coordinated with the other plan according to regulations on “Coordination of Benefits”. Covered California’s standard benefit design requires that stand alone dental plans offering the pediatric dental essential health benefit, such as this CDN plan, whether as a separate benefit or combined with a family dental benefit, cover benefits as a secondary dental benefit plan payer. This means that the primary dental benefit payer is a health plan purchased through Covered California which includes pediatric dental essential health benefits. Your primary dental benefit plan will pay the maximum amount required by its plan contract with you when your primary dental benefit plan is coordinating its benefits with CDN. This means that CDN will pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage when a primary dental benefits plan is coordinating benefits with your CDN plan, or your total out-of- pocket cost payable under the primary dental benefit plan for benefits covered under your CDN plan. These regulations determine which plan is primary and which is secondary under various circumstances. Generally, they result in a group plan being primary over an individual plan and that a plan covering the member as a subscriber is primary over a plan covering the member as a dependent. Typically, Coordination of Benefits will result in the following: If the other coverage is a group indemnity plan: • If the group indemnity coverage is primary, the provider will usually bill the carrier for their Usual and Customary Fees, and the member will be charged the copayment under the secondary plan less the amount received from the primary coverage. • If the group indemnity coverage is secondary, the provider will bill the carrier for the amount of copayments under the primary plan, and the member will be responsible for the copayments under the primary plan less the amount paid by the secondary carrier. If the other coverage is a prepaid plan: • If the provider participates in both plans, the member should be charged the lower copayment(s) of the two plans. • If the provider does not participate in both plans, the plan that the provider participates in will be primary, and the other plan will typically deny coverage becau...
Coordination of Benefits. When an employee is eligible at the same time for benefits under Chapter 616 or 617 of the Nevada Revised Statutes and for sick leave or injury leave benefit, the amount of sick leave or injury leave benefit paid to said employee shall not exceed the differences between their normal salary and the amount of any benefit received, exclusive of payment of medical or hospital expenses under Chapter 616 or 617 of the Nevada Revised Statutes for that pay period. Any usage of such sick leave shall be deducted from the employee’s sick leave balance.
Coordination of Benefits. Employees who are absent due to illness or injury covered by worker’s compensation benefits may use accrued sick leave to make up the difference between the employee’s regular salary and the amount received in workers’ compensation benefits.
Coordination of Benefits. If the insured has another policy that provides benefits also covered by this policy, benefits will be coordinated. All claims incurred in the country of residence must be submitted in the first instance against the other policy. This policy shall only provide benefits when such benefits payable under the other policy have been paid out and the policy limits of such policy have been exhausted. Outside the country of residence, Xxxxx’x will function as the primary insurer and retains the right to collect any payment from local or other insurers. The following documentation is required to coordinate benefits: Explanation of Benefits (EOB) and copy of bills covered by the local insurance company containing information about the diagnosis, date of service, type of service, and covered amount.
Coordination of Benefits. If a Contractor’s QHP provides coverage for the Pediatric Dental Essential Health Benefit, Contractor shall include a Coordination of Benefits (COB) provision in its Evidence of Coverage or Policy Form that (i) is consistent with Health and Safety Code § 1374.19 or Insurance Code § 10120.2, and (ii) provides that the QHP is the primary dental benefit plan or policy under that COB provision. This provision shall apply to Contractor’s QHPs offered both inside and outside of Covered California for the Individual Market, except where 28 CCR § 1300.67.13 or 10 CCR § 2232.56 provides for a different order of determination for COB in the small group market.
Coordination of Benefits. If you have medical coverage under any other Health Benefits Plan, other public or private group programs, or any other health insurance policy, the benefits provided or payable hereunder shall be reduced to the extent that benefits are available to you under such other plan, policy or program. The rules establishing the order of benefit determination between this Agreement and any other plan covering a Member not on COBRA continuation on whose behalf a claim is made are as follows: ⮚ Employee/Dependent Rule • The plan, which covers you as an employee, pays first. • The plan, which covers you as a Dependent, pays second. ⮚ Birthday Rule for Dependent children of parents who are not separated or divorced • The plan, which covers the parent whose birthday falls earlier in the year, pays first. The plan, which covers the parent whose birthday falls later in the year, pays second. The birthday order is determined by the month and the day of birth, not the year of birth. • If both parents have the same month and day of birth, the plan that Covered the parent longer, will pay claims first. The plan which covered the parent for a shorter period of time pays second. ⮚ Dependent children of separated or divorced parents • The plan of the parent decreed by a court of law to have responsibility for medical coverage pays first. • In the absence of a court order: o The plan of the parent with physical custody of the child pays first. o The plan of the Spouse of the parent with physical custody (i.e., the stepparent) pays second. o The plan of the parent not having physical custody of the child pays third. ⮚ Active/Inactive Employee • The plan, which covers you as an active employee (or Dependent of an active employee), pays first. • The plan, which covers you as a retired or laid-off employee (or Dependent of a retired or laid-off employee), pays second. ⮚ Longer/Shorter Employment • In the case where you are the Subscriber under more than one group health insurance policy, then the plan that has Covered you for a longer period of time will pay first. A change of insurance carrier by the group employer does not constitute the start of a new plan. ⮚ No Coordination Provision • In spite of the rules listed above, the plan that has no provision regarding coordination of benefits will pay first. ⮚ If you are covered under a motor vehicle or homeowner’s insurance policy which provides benefits for medical expenses resulting from a motor vehicle accident or accident in your ...
Coordination of Benefits i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense.
Coordination of Benefits. Contractor’s Qualified Dental Plans shall include a Coordination of Benefits (COB) provision in its Evidence of Coverage or Policy Form that (1) is consistent with Health and Safety Code § 1374.19 and Insurance Code § 10120.2 and (2) provides that the Qualified Dental Plan is the secondary dental benefit plan or policy under that COB provision to any Qualified Health Plan that provides the Pediatric Dental Essential Health Benefit. This provision shall apply to Contractor’s QDPs offered both inside and outside of the Covered California for the Individual Market and Covered California for Small Business, except where 28 CCR § 1300.67.13 or 10 CCR § 2232.56 provides for a different order of determination for COB in the small group market.
