Coordination of Benefits (COB) Sample Clauses

Coordination of Benefits (COB). The Contractor shall actively pursue, collect and retain all monies available from all available resources for services to Members under this Contract except where the amount of reimbursement the Contractor can reasonably expect to receive is less than estimated cost of recovery. Cost effectiveness of recovery is determined by, but not limited to, time, effort, and capital outlay required in performing the activity. The Contractor shall specify the threshold amount or other guidelines used in determining whether to seek reimbursement from a liable third party, or describe the process by which the Contractor determines seeking reimbursement would not be cost effective. The Contractor shall provide the guidelines to the Department for review and approval. COB collections are the responsibility of the Contractor or its Subcontractors. Subcontractors must report COB information to the Contractor. Contractor and Subcontractors shall not pursue collection from the Member but directly from the third party payer. The Contractor shall only recoup payments to providers if the third party payer is Medicare. Access to Covered Services shall not be restricted due to COB collection. The Contractor shall maintain records of all COB collections. The Contractor must be able to demonstrate that appropriate collection efforts and appropriate recovery actions were pursued. The Department has the right to review all billing histories and other data related to COB activities for Members. The Contractor shall seek information on other available resources from all Members. In order to comply with CMS reporting requirements, the Contractor shall submit a monthly COB Report for all member activity which the Department or its agent shall audit no less than every six (6) months. Additionally, Contractor shall submit a report that includes subrogation collections from auto, homeowners, or malpractice insurance, etc.
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Coordination of Benefits (COB). The activities involved in determining Medicaid benefits when a member has coverage through an individual, entity, insurance, or program that is liable to pay for health care services.
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Coordination of Benefits (COB). If an Eligible Person or Eligible Dependent is covered for Dental Services or Benefits by another third party provider’s contract, arrangement, or insurance carrier, the Plan’s liability for payment will be determined as follows: A. A plan with no rules for coordination with other Benefits will be deemed to pay its Benefits before a plan that contains such rules. B. A plan that covers a person other than as a Dependent will be deemed to pay its Benefits before a plan that covers the person as a Dependent. C. A plan that covers the person as a Dependent of a person whose birthday comes first in a Calendar Year will be primary to the Plan that covers the person as a Dependent of a person whose birthday comes later in that Calendar Year. If a plan does not have this provision regarding birthdays, the rule set forth in that plan will determine the order of Benefits. If the person for whom claim is made is a Dependent child and the parents are separated or divorced: 1. If there is a court decree which would establish financial responsibility for the medical, dental, or other health care expenses with respect to the child, the Benefits of a plan which covers the child as a Dependent of the parent with such financial responsibility shall be determined before the Benefits of any other plan which covers the child as a Dependent child. 2. If there is not a court decree which would establish financial responsibility for the medical, dental, or other health care expenses with respect to the child: a. If the custodial parent has not remarried, the Benefits of a plan which covers the child as a Dependent of the custodial parent will be determined before the Benefits of a plan which covers the child as a Dependent of the noncustodial parent. b. If the custodial parent has remarried, the Benefits of a plan that covers the child as a Dependent of the custodial parent shall be determined before the Benefits of a plan which covers that child as a Dependent of the stepparent or the noncustodial parent. The Benefits of a plan which covers that child as a Dependent of the stepparent will be determined before the Benefits of a plan which covers that child as a Dependent of the noncustodial parent. D. If A, B, andƒor C above do not establish an order of payment, the Plan under which the person has been covered for the longest period of time will be deemed to pay its Benefits first, except that: 1. The Benefits of a plan that covers the person as a laid−off or retired Employee, or...
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Coordination of Benefits (COB). The coordination of benefits provision of this policy applies when a person has health care coverage under more than one Plan as defined below. The order of benefit determination rules govern the order in which each Plan pays a claim for benefits. • The Plan that pays first is the “Primary Plan”. The Primary Plan must pay benefits in accordance with 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.” The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense. The HMO will provide access to Covered Services first and determine liability later. In addition to the defined terms in the Definitions section of this policy, the following definitions apply to this provision:
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Coordination of Benefits (COB). Coordinating with other valid coverage for payment of Covered Services. All other group and nongroup or direct-pay insurance policies or health care benefits (excluding Indian Health Service and Medicaid coverage) that provide payments for medical or other care services constitute other valid coverage.
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Coordination of Benefits (COB). County acknowledges that Medi-Cal is the payor of last resort. County shall coordinate benefits with other programs or entitlements recognizing where Other Health Coverage (“OHC”) is primary coverage in accordance with CalOptima Program requirements.
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Coordination of Benefits (COB). This section tells you how other health insurance you may have affects your coverage under this Plan.
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Coordination of Benefits (COB) is a program which determines which plan or insurance policy will issue primary payment when two insurance companies cover the same benefits. If one of the plans is a Medicare Health Plan, Federal Law establishes which plan is the Primary Payer. It is the process of determining the respective responsibilities of two or more health care insurance plans that have financial responsibility over a medical claim.
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Related to Coordination of Benefits (COB)

  • 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. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

  • Coordination of Benefits and Subrogation Professional Provider agrees to and shall cause Practitioners to cooperate with Highmark’s coordination of benefits efforts consistent with a Member’s Plan Document and the Administrative Requirements. Professional Provider shall make efforts to collect and provide to Highmark other payor information as requested under established Highmark billing requirements. Professional Provider further agrees to and shall cause Practitioners to cooperate with Highmark or Health Plan in efforts to pursue subrogation claims against others where a person or entity other than Highmark or Health Plan has primary responsibility for payment.

  • Retention of Benefits Union leave under the following four (4) sections will be unpaid. The Employer will maintain regular pay and ▇▇▇▇ the Union for the costs of the employee’s salary and benefits. If the Union member is part-time or casual, and the leave is greater than their normal work hours, the Employer will pay the employee for the full length of the leave requested by the Union. The Employer will ▇▇▇▇ the Union for these days as noted above. The Union will pay these invoices within twenty-eight (28) days. Union leave is not unpaid leave for the purposes of Article 22.02 [i.e. such leave will not affect the employee’s benefits, seniority or increment anniversary date].

  • Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates: 1.09.01 the date the member is no longer disabled from performing the duties of their regular position, or any alternative employment made available to the member by the City. 1.09.02 the date the member's Income Protection benefits have been expended. 1.09.03 the date the member dies.

  • Termination of Benefits Except as provided in Section 2 above or as may be required by law, Executive’s participation in all employee benefit (pension and welfare) and compensation plans of the Company shall cease as of the Termination Date. Nothing contained herein shall limit or otherwise impair Executive’s right to receive pension or similar benefit payments that are vested as of the Termination Date under any applicable tax-qualified pension or other plans, pursuant to the terms of the applicable plan.