Coordination of Benefits Sample Clauses

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. 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. Provide Covered Services to Members even though there might be coverage by another party under workers' compensation, occupational disease, or other statute. Provider shall xxxx the appropriate responsible party for Covered Services and shall provide information to BCBSM regarding the applicability of such statutory coverage; Request information from Members regarding other payers that may be primarily responsible for Members’ Covered Services, pursue payment from such other responsible payers, and shall xxxx BCBSM only for Covered Services not paid by the primary payers. All payments received from other primary payers for Covered Services shall be promptly credited against or deducted from amounts otherwise payable by BCBSM for such services. Except where BCBSM payment is secondary to Medicare, payments by BCBSM as a secondary payer shall not exceed the amount which would otherwise be payable by BCBSM as primary payer under this Agreement. Provider agrees to submit claims to the primary payers before submitting them to BCBSM;
Coordination of Benefits. If the Executive’s employment is terminated for any reason described in Sections 4(d) or (e) and, after such termination, Executive becomes entitled to payments under Section 4(f), the Executive shall receive the payments described in Section 4(f), at the time and in the form described in Section 4(f), less the amount of any payments previously paid that are described in Sections 4(d) or (e).
Coordination of Benefits. Employees who are absent due to illness or injury covered by workerscompensation 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, taking into account the tax-free nature of workers’ compensation benefits.
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 EmploymentIn 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. The plan provisions relating to the coordination of benefits will follow the provisions under the plan in 2013. Dental Plan Feature Delta Dental PPO 1500 Delta Dental PPO 2000 PPO Dentist Premier and Non-PPO Dentist PPO Dentist Premier and Non-PPO Dentist Diagnostic and Preventative X-rays, Study Models Prophylaxis (cleaning), Periodontal Maintenance, Fissure Sealants, No cost and no deductible. 20% of the cost and no deductible. No cost and no deductible. 20% of the cost and no deductible. Topical Fluoride, Space Maintainers, Resin Restoration Restorative Fillings, Stainless Steel Crowns, Oral Surgery (teeth removal) Denture Insertion Treatment of pathological conditions and traumatic mouth injuries Deductible and 20% of the cost Deductible and 30% of the cost Deductible and 20% of the cost Deductible and 30% of the Cost General Anesthesia Intravenous Sedation Deductible and 20% of the cost Deductible and 30% of the cost Deductible and 20% of the cost Deductible and 30% of the Cost Endodontics Pulpal and root canal treatment services: pulp exposure treatment, pulpotomy, apicoetomy Deductible and 20% of the Cost Deductible and 30% of the cost Deductible and 20% of the cost Deductible and 30% of the cost Major Crowns, veneers or onlays, crown build ups, Post and core on endodontically treated teeth, Deductible and 50% of the cost Deductible and 50% of the cost Deductible and 50% of the cost Deductible and 50% of the cost Dentures, Fixed partial dentures, Deductible and 50% of Deductible and 50% of Deductible and 50% of Deductible and 50% of the cost (fixed bridges) inlays when used as a retainer, (fixed bridge) removable partial dentures, adjustment or repair to prosthetic appliance, Surgical placement or removal of implants the cost the cost the cost Annual Maximum that the plan pays $1,500 per person $1500 per person $2,000 per person $2000 per person Annual Deductible Per person $50 $50 $50 $50 Annual Deductible Family Maximum $150 $150 $150 $150 Orthodontia Not covered 50% after $50 lifetime deductible $2,000 lifetime maximum Dental Premiums The following are the premium contribution for the nurses for each pay period for a total of twenty four (24) pay periods for the year. Level of Benefit Delta Dental PPO 1500 Delta Dental PPO 2000 Full Time 0000 0000 0000 0000* Employee Only $0.00 $0.00 $3.76 13% of premium Employee and child(ren) $4.47 30% of premium $10.49 39% of premium Employee and Spouse/Partner $7.45 30% of premium $14.98 39% of premium Employ...
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, Bupa Insurance Limited 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. When a claim is denied due to third party liability, the MCP must timely share appropriate and available information regarding the third party to the provider for the purposes of coordination of benefits, including, but not limited to third party liability information received from ODM.