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Coordination of Benefits
Under HIPAA , HHS adopted standards for electronic transactions, including for coordination of benefits.
The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information. See the Coordination of Benefits Transactions Basics.
About Coordination of Benefits
Coordination of benefits (COB) applies to a person who is covered by more than one health plan.
The COB regulations, as well as the HIPAA Privacy Act, permit Medicare to coordinate benefits with other health plans and payers to reduce administrative burden and enable patients to obtain payment of the maximum benefit they are allowed. The same applies in situations where Medicare is the secondary payer and a provider must file a COB claim to Medicare.
COB claims are those sent to secondary payers with claims adjudication information included from a prior or primary payer (the health plan or payer obligated to pay a claim first). These claims can be sent 1) from provider to payer to payer or 2) from provider to payer. Additional information about Medicare's COB/claims crossover process is available.
HIPAA Adopted Standards
In January 2009, HHS adopted Version 5010 of the ASC X12N 837 for coordination of benefits. For more information, see the official ASC X12N website.
For COB pharmacy claim transactions, HHS adopted NCPDP Telecommunications Standard Version D.0.
These standards apply to all HIPAA-covered entities , health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.
- Coordination of Benefits Transactions Basics
- National Council for Prescription Drug Programs (NCPDP)
- COB/Claims Crossover Process
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Coordination of Benefits
Coordination of Benefits (COB) is a provision in most health plans that allow families with two wage earners covered by health benefit plans to receive up to 100% coverage for medical services. COB rules determine which plan is primary for you, your spouse and your dependent children. Under COB your plan is primary for you, and your spouse's plan is primary for him or her, and the " Birthday Rule " determines children's primary coverage.
How it Works
First, the primary plan pays your claims as if there were no other insurance. Then your spouse's plan pays for what your plan did not, providing it is a covered benefit. For example, if your doctor's visit costs $80 and your health plan, which is primary, pays $50 of that, your secondary health plan could pay the remaining $30. Remember, the claim must be considered a covered expense by your spouse's plan.
COB is an industry standard that was created by the National Association of Insurance Commissioners (NAIC) in conjunction with the insurance industry. It is not a law. COB can be complicated, especially if you and your spouse have different plan types, for instance, if you have a PPO type plan and your spouse has an HMO. Here is how COB generally works when you and your spouse are covered under each other's health plan:
- The plans will not pay more than 100% of the cost of the medical treatment, nor will it pay for a treatment or service not covered under that plan.
- In determining which plan is primary and which is secondary, a plan without a COB provision is generally considered primary.
- When both have COB rules, the plan in which you are enrolled as an employee or as the main policyholder is primary. The plan in which you are enrolled as a dependent - on your spouse's plan - would be secondary.
- In addition, if you have COBRA coverage as well as coverage with another plan in which you are enrolled through an employer, your COBRA plan is secondary and your employer's plan is primary.
- The " Birthday Rule " applies only to children.
- If none of the above provisions determines which plan is primary, the plan covering you the longest is typically considered primary (although some insurers might say the claims are shared equally by both plans).
Your situation determines which of these provisions applies. If you have questions, contact the Office of the Healthcare Advocate toll-free at 1 (866) HMO-4446.
Individual and Family
What is Coordination of Benefits?
By colin bean updated on february 08, 2023.
When a person is covered by two health plans, coordination of benefits is the process the insurance companies use to decide which plan will pay first for covered medical services or prescription drugs and what the second plan will pay after the first plan has paid. Insurance companies coordinate benefits for several reasons:
- To avoid paying twice for the same covered service. Duplicate payments could result in paying more than the service cost!
- To determine which plan is primary, which means the insurer pays for covered services first according to the benefits provided by the plan. The other insurer pays secondary, which means it pays the remaining unpaid balance according to the benefits provided by its plan.
- To help keep the cost of health and prescription drug costs affordable.
In today’s world of dual-income, working couples, working Medicare beneficiaries, and the ability to extend dependent coverage to children up to age 26, dual health coverage occurs frequently. Understandably, most health plans have rules to determine which plan will pay primary and which plan will pay secondary. These rules are typically outlined in the “coordination of benefit” provisions in your summary plan description, the document that explains your benefits and how they are determined.
How does coordination of benefits work?
Coordination of benefits allows two insurance carriers to determine their fair share of the cost for covered services. Your out-of-pocket cost for services is limited to the amount, if any, that remains unpaid by the insurers. Covered services refers to the medical care, equipment, services, or prescription drugs the insurers include in their plan benefits.
Coordination of benefits examples
Listed below are four common situations when coordination of benefits occurs:
- You are covered under your own insurance plan with your employer, and covered as a dependent under your spouse or partner’s employer-sponsored plan;
- Your spouse or partner is covered under his or her own insurance plan and as a dependent under your insurance plan;
- Your dependent children are covered under your insurance plan and your spouse or partner’s plan;
- You are still working at age 66, and covered by your employer’s group health plan and Medicare Part A (hospital insurance).
In each of these scenarios there is a primary payor and secondary payor. You or your healthcare provider submits the claim to the primary payor first.
You have coverage under your own insurance plan and under your spouse or partner’s plan: your own insurance plan is always the primary payor; your spouse or partner’s insurance plan is the secondary payor.
You (or your healthcare provider on your behalf) submit a medical or prescription drug claim to your own insurance plan first. Your insurance plan pays its portion of the claim. If your insurance plan doesn’t cover the full claim amount, you can submit the claim to your spouse or partner’s insurance plan, with the explanation of benefits statement from your insurance plan, requesting payment for the remainder of the expense.
When submitting a claim to your partner’s insurance, you may not be reimbursed for the entire remaining balance. This will depend on the amount of coverage offered by your partner’s insurance plan.
Your spouse or partner’s health insurance plan is the primary payor and receives his or her claims first, determines benefits, and pays accordingly. Your plan is the secondary payor. Upon receiving the claim and the primary insurer’s explanation of benefits, the secondary payor determines what portion of the balance of the bill, if any, is your plan’s responsibility to pay. Your spouse or partner pays the remaining balance, if any.
Your children are dually insured by your health insurance plan and your spouse or partner’s plan. In most cases, the health plans will perform coordination of benefits using the “birthday rule.” This means if your birthday month occurs earlier in a calendar year than your spouse or partner’s, your plan will be primary and the other plan will be the secondary payor. If you share the same birthday month as your spouse or partner, the plans will usually assign the order of payors so that the plan that has provided coverage the longest time is the primary payor and the other plan is secondary payor. If you and your spouse are divorced, the custodial parent’s health plan is usually primary, unless a court decree specifies the parent who is responsible for the children’s health insurance.
Your employer’s group health plan is the primary payor if the company employs 20 or more people. It receives your claim first, determines benefits, and pays according to the plan’s benefits. Medicare is the secondary payor, and determines what portion of the balance of the bill, if any, Medicare will pay. In this hypothetical situation, you have Medicare Part A, which provides coverage for hospital services. If you submitted a claim for a physician office visit, Medicare Part A would deny the claim and pay nothing because it does not cover physician office exams. (Medicare Part B does.) If you submit a claim for a hospital stay, Medicare Part A will determine what portion of the balance of the bill, if any, is payable according to the Medicare Part A benefits, which typically includes a daily copayment for hospital stays.
What are the rules of coordination of benefits?
The National Association of Insurance Commissioners (NAIC) released its first set of model coordination of benefits guidelines in 1971. This model was to serve as an example for employers and state legislatures to adopt as a consistent set of coordination of benefits rules. Many plans use the model coordination provisions. Highlights of the model coordination of benefits guidelines follow.
- Most coordination of benefit provisions include the following general rules for employees and spouses covered by two group health plans: The plan that covers the individual as an employee will generally pay primary and the plan that covers the individual as a dependent will generally be the secondary payor.
- The “birthday rule” is common for children covered by two employer group health plans. In this situation, the plan covering the parent whose birthday falls first in the year will pay primary on the children; the other parent’s plan becomes the secondary payor.
- If a person has COBRA continuation coverage or any state-mandated continuation of coverage, the continuation coverage is secondary.
- If neither plan spells out coordination of benefit rules, the plan that covered the person for the longer time is usually primary.
How do I know what my cost for medical care or prescription drugs will be after my insurance companies coordinate benefits?
Coordination of benefit provisions do not allow the claimant to receive more than 100% of the eligible charges between both health plan payments. Furthermore, plans take different approaches when they calculate coordination of benefit payments. Usually, you can find out how your insurance plans perform coordination of benefits by reading the coordination of benefits provision in your Summary Plan Description or policy.
If you don’t find the provision, or have questions about how coordination of benefits works for one or both plans, ask for an explanation from the plan administrator or insurance company. Two common methods of coordination of benefits and payment results follow.
Full coordination of benefits method
The primary plan calculates the claim payment as if there is no other insurance involved. The secondary carrier also calculates what benefit amount would have been paid for the claim if there were no primary carrier involved. The primary plan pays the benefit as calculated. The secondary carrier pays the balance if its calculation shows at least that amount would have been payable if no other coverage had been in place. For example, let’s say you are covered by two plans, one has a $500 deductible and the other a $25 office visit copay that apply to physician care in the office. You incur $100 expense at the doctor’s office. Your primary payor applies the $100 toward meeting the $500 deductible and pays nothing. The secondary payor applies the plan’s $25 copay (calculating payment as if no other coverage is in place) and pays $75. You would be responsible for paying the $25 office visit copay.
Non-duplication coordination of benefits method
The secondary plan does not reimburse any more on the claim than it would have paid, if it were the primary payor. The secondary carrier reviews the primary paid amount. If the primary carrier’s paid amount is equal to or more than what the secondary payor would have paid on its own, no benefit is payable. In this case, if you incur a $100 doctor office visit expense and the primary payor pays $80, the secondary payor with a $25 office visit copay pays nothing because the primary plan paid more than what the secondary payor would have paid on its own.
When you are covered by two plans, you will know, ultimately, what amount you owe on a medical or prescription drug claim by reading the second payor’s explanation of benefits. This statement will show the amount you owe, the amount the second payor paid, and the amount that was disallowed because it was previously paid by the primary payor and/or exceeded the contract rate of the provider of service.
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Coordination of Benefits (COB)
From determining whether your insurance will cover the services you need to understanding how much your care will cost out of pocket, navigating the health care system can be tricky. This is especially true when more than one insurance plan could potentially cover your medical expenses. Coordination of benefits is the process by which insurance companies decide who is responsible for covering the cost of your care in this situation.
At SSM Health, we understand that this process can be confusing. Our customer service team is available Monday through Friday from 8 am – 5 pm CST to answer your questions and clarify the process, so you can be sure you have coverage when you need it.
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What is coordination of benefits?
Coordination of benefits (COB) is part of the insurance payment process for when more than one insurance plan potentially covers the services provided. Insurance companies coordinate benefits by following certain general principles to establish the sequence in which each will pay. The primary payer is responsible for the largest share, while secondary payers cover a portion of the remainder. Insurance companies determine the order prior to paying claims in order to ensure they pay the right amount.
How do I handle coordination of benefits?
Your insurance company will ask you to complete a form disclosing any other health plans you may have in place. They may mail you a form requesting the information, ask that you fill out the information online, or request that you call them directly. To complete the coordination of benefits requirement, you will need to contact your insurance company and provide the requested information.
You should keep a copy of any documents for your records in case any questions arise in the future. If you contact the insurance company on the phone, you should record the representative’s name and the call reference number.
What happens if the coordination of benefits is not completed?
If the coordination of benefits status is not updated, it is possible that your insurance company will refuse to pay any claims until the issue is resolved. They may identify the amount owed as “patient responsibility,” leaving you with the full balance for your visit. Complying with the insurance company’s request will save you time and prevent headaches down the road.
Do I still need to do this if I only have one health insurance plan?
Yes. Even though you only have one health insurance plan at this time, your insurance company may refuse to pay your claims until verification is received. Insurance companies routinely check on the coordination of benefit status and may require it even when there are no other coverages to coordinate. Complying with their requests will facilitate a smoother billing process for you as a customer.
How do I contact my insurance company regarding coordination of benefits?
The most common methods for contacting your insurance company are by phone, through their website, or through written correspondence.
What information do I need to gather?
You should gather the following documents:
- ID cards from all other health insurance plans.
- Full name and date of birth for each person on your plan that is covered by other insurance.
Where do I find policy information?
When you gather ID cards from all other insurance plans, review the card for the policy number, group number, and the names of anyone else you cover on your plan. Please note that your policy number may also be identified as a member ID, participant ID, or another synonym.
Contact numbers for the insurance company are usually on the back of the card.
Can I contact my insurance company online?
Whether you can complete coordination of benefits information online will depend on your insurance company and what options they provide. Contact information for several health plan providers is listed below for your convenience.
- Claim Coordination Review
- Member Login
- COB Smart Frequently Asked Questions
- Frequently Asked Questions
- Coordination of Benefits Questionnaire
- Transparency in Coverage
- Health Benefits
- Illinois Department of Human Services
- TTY/TDD: 1-866-324-5553
- Reporting Other Health Insurance
- TTY/TDD: 1-855-797-2627
- Benefit Change Reporting
- TTY/TDD: 800-735-2966
- Update / Change Health Insurance Information
- United HealthCare
- Account Login
- Individual & Marketplace Plans: 866-514-4194 (TTY: 711)
- WellFirst Employee Health Plan: 877-274-4693 (TTY: 711)
When is coordination of benefits needed?
While your insurance company may inquire about other coverage at any time, there are several common situations when coordination of benefits is needed and/or that may prompt your insurance company to verify your coverage:
- When you have more than one medical insurance plan.
- When a child is covered by more than one insurance plan. In this scenario insurance companies generally agree that whichever policyholder has the earlier birthday in the year, based on the month, will be designated the primary.
- When you have Medicare and another insurance plan through work. Medicare has a set of rules that determine when Medicare pays first and when it does not. If Medicare has incorrect information regarding your coverage, they will not pay the claim until that is resolved.
- When a baby is added to your policy. Insurance companies will often inquire about other coverage for the mother, as well as the baby.
- At the beginning of the year. Insurance companies will often request coordination of benefits information in case you have picked up another coverage.
- When accidents occur, insurance companies will inquire about other coverage that might cover the medical treatment, such as liability insurance (in the case of an automobile accident) or workers’ compensation insurance (in the case of a work-related accident). How these cases are handled depends on state laws and the type of insurance involved.
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Coordination of Benefits: Everything You Need to Know
COB, or coordination of benefits, occurs when an individual is in possession of more than one insurance policy and it comes to processing a claim. 4 min read
Also referred to as COB, coordination of benefits occurs when an individual is in possession of more than one insurance policy and when it comes to processing a claim, the policies are assessed to determine which will be assigned with the primary responsibility for covering the predominant share of the claim costs.The process also involves assessing the extent that other policies held will contribute toward the claim. This article will provide you with everything that you need to know about coordination of benefits.
What Is Coordination of Benefits?
The primary intentions of coordination of benefits are to make sure that individuals who receive coverage from two or more plans will receive their complete benefit entitlement and to prevent benefits from being duplicated when an individual has more than one policy in place. This process covers insurance pertaining to several sectors including health insurance, car insurance, retirement benefits, workers compensation, and others.
The order in which the insurance policies are coordinated is dictated by insurance law and cannot be decided by a company or an individual. This process takes place only when multiple insurance plans are involved. If only one plan is held, then all responsibility is put onto the sole plan.
Predominantly, coordination of benefits happens when an individual has two plans in place (primary and secondary), but it may also include a tertiary plan in some circumstances. The primary insurance plan is given the responsibility of being the first payer, the secondary plan is the second payer, and so on depending on how many plans the individual holds.
Why Is COB Important?
There are numerous reasons why COB is an important process. These are summarized below:
- A lack of coordination between the plans a person holds can result in the claim not being paid until the COB has been confirmed, thus potentially causing financial difficulties.
- Either the individual or the insurance provider could be subjected to expenses that they did not need to pay if the insurance plans are not coordinated correctly.
Order of Benefit Determination
The primary plan is always considered as the predominant provider of benefits, and it must provide these as though the claim holder does not have a second or third policy in place. The COB provisions that are specified in the insurance policy outline which plan is the primary plan. Once identified, the primary plan's benefits are applied to the claim first.
It is important to note that the primary plan is always considered as the first payer, regardless of the specifics written in its clauses. This means that any plan that does not include the COB provisional clause may not incorporate the benefits offered by a claimant's other plan into their considerations when assessing what benefits are due.
Any unpaid balance owed to the patient is typically paid by the claimant's second plan, within the limits of its responsibility. This secondary insurance plan can take the benefits of the patient's other plans into consideration only when it has been confirmed as being the secondary — not primary — plan.
The payments that are delivered to the patient by their combined insurance plans do not exceed 100 percent of the charges for necessary covered services. The benefits are usually coordinated between all of the plans held by the patient.
If a family is making a claim, each individual and their COB will be assessed separately, as there is a possibility that the order of plans and benefits may differ between each member.
There may be some differences to the "order of benefit determination" as laid out here if the claimant's policy is held with Medicare, but otherwise, these rules should be followed as a standard process.
Understanding Various COB Rules
Common COB circumstances and how the COB rules are then applied are outlined below.
- Plan Type Rule If the individual has both a commercial insurance plan and Medicaid, then the commercial plan will always be considered as the primary policy, and Medicaid is secondary.
- Subscriber or Dependent Rule If a patient subscribes to two or more policies, where one policy is as a subscriber, and another is as a dependent, then the policy under which they are classified as a subscriber is the primary policy, and that where they are a dependent will fall as the secondary policy.
- Timeline Rule If the patient is the primary subscriber to two commercial plans, then the plan to which they have been subscribed the longest is considered as the primary plan, and the newer plan is the secondary.
- Employer Coverage Rule If the individual has coverage both through their employer and as a dependent through another commercial plan, then the employer-operated plan will always be considered as the primary plan.
- 1. The birthday rule of the parent (whoever's occurs earlier in the year) and,
- 2. The length of policy rule of the policy holders (whichever commenced first).
- Dependent Child (Parents Not Separated or Divorced) Rule If a child's parents are together, then determining the primary plan is done by using the birthday rule (i.e. whoever was born earlier is responsible).
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Coordination of benefits (COB) occurs when a patient is covered under more than one insurance plan. This process lets your patients get the benefits they are entitled to. It helps determine which company is primarily responsible for payment. It also helps avoid overpayment by either plan and gets you paid as quickly as possible.
When a patient comes to you, you can submit an eligibility and benefits inquiry. We will inform you if the patient is covered and which plan is primary.
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- Commercial insurance claims in which another payer is primary and Aetna is secondary
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When Aetna is secondary, you will need to include the appropriate code on your claim that tells us information about the primary payer’s payment.
Contact the practice management support team and/or the clearinghouse you use to submit your electronic claims. They may have their own guidelines or tips about submitting COB claims.
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* We can accept both Medicare Part A and Part B claims electronically from Medicare. If the Medicare electronic remittance advice (ERA) or Explanation of Payment (EOP) contains an "MA 18" or "N89" remark code, the Medicare carrier has automatically sent us your claim. In these cases, you don't have to send us a Medicare primary COB claim.
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Visit the CAQH website for more information on COB Smart
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- The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.
- Applies to: Aetna Choice ® POS, Aetna Choice POS II, Aetna Medicare ℠ Plan (PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund ® products, Aetna Health Network Only ℠ , Aetna Health Network Option ℠ , Aetna Open Access ® Elect Choice ® , Aetna Open Access HMO, Aetna Open Access Managed Choice ® , Open Access Aetna Select ℠ , Elect Choice, HMO, Managed Choice POS, Open Choice ® , Quality Point-of-Service ® (QPOS ® ), and Aetna Select ℠ benefits plans and all products that may include the Aexcel ® , Choose and Save ℠ , Aetna Performance Network or Savings Plus networks. Not all plans are offered in all service areas.
- All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search."
- The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT ® ), copyright 2022 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
- The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT ® ")
- CPT only Copyright 2022 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
U.S. Government Rights
This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
Disclaimer of Warranties and Liabilities.
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".
The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.
This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.
Dental clinical policy bulletins
- Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
- While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.
- Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
- Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
- Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
Medical clinical policy bulletins
- Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.
- While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
- Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.
- CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
- Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern.
- In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.
See CMS's Medicare Coverage Center
- Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.
- Since Clinical Policy Bulletins (CPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
- While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. In addition, a member may have an opportunity for an independent external review of coverage denials based on medical necessity or regarding the experimental and investigational status when the service or supply in question for which the member is financially responsible is $500 or greater. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA (e.g., government, school boards, church) plans.
See Aetna's External Review Program
- The five character codes included in the Aetna Clinical Policy Bulletins (CPBs) are obtained from Current Procedural Terminology (CPT®), copyright 2015 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.
- The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs) is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins (CPBs) should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")
CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.
You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.
Go to the American Medical Association Web site
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- Understanding My Benefits
What's coordination of benefits?
Who is this for.
Blue Cross Blue Shield of Michigan and Blue Care Network members under age 65.
Sometimes two insurance plans work together to pay claims for the same person. That process is called coordination of benefits. Insurance companies coordinate benefits to:
- Avoid duplicate payments by making sure the two plans don’t pay more than the total amount of the claim
- Establish which plan is primary and which plan is secondary—the plan that pays first and the plan that pays any remaining balance after your share of the costs is deducted
- Help reduce the cost of insurance premiums
When one person has two health insurance plans
You have custody of your 8-year-old son. He’s on your health insurance plan and your ex-husband’s plan. When your son goes to the doctor, we’ll review the claim to figure out which plan is primary and which plan is secondary.
That’s coordination of benefits.
Health insurance and auto insurance
You hit a deer with your car, hurt your knee and need to go to a doctor. Michigan auto insurance policies must include coverage for car-related injuries, called personal injury protection. But in most cases your health insurance is primary. So your health plan will pay first, and if there are expenses left over not covered by your plan, your auto insurance will pay those.
That’s coordination of benefits, too.
Coordination of benefits also happens when you’re injured and it’s not your fault. Here’s an example.
You’re in a store and slip on a wet floor. You hurt your elbow and need to go to a doctor. Because the accident wasn’t your fault, your health insurance company will contact the store’s insurance company to get them to help pay for your care.
The process of getting the other insurance company to pay is called subrogation.
If we contact you about coordination of benefits or subrogation
When we send you a form that asks if you have more than one health insurance plan, you should respond, even if the answer is no.
You don’t have to wait for us to contact you. You can:
- Let us know anytime you or anyone on your plan adds or drops other health insurance
- Confirm your existing coordination of benefits information or update it when your plan renews each year; then we won’t mail you a form
If we contact you about subrogation, you should also respond. Learn more about subrogation .
- Coordination of Benefits Form
- Subrogation Form
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Cooked corn on the cob typically lasts in the refrigerator for five to seven days. Corn that has been removed from the cob and cooked stays fresh in the refrigerator for the same amount of time.
Boil corn on the cob until tender or for approximately 10 minutes. Preparation time is five minutes, so the corn is ready to eat in 15 minutes. Remove the husks and the silk from six ears of corn on the cob. Fill a large pot 3/4 of the way ...
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When a person is covered by two health plans, coordination of benefits is the process the insurance companies use to decide which plan will
Coordination of benefits (COB) is part of the insurance payment process for when more than one insurance plan potentially covers the services provided.
COB, or coordination of benefits, occurs when an individual is in possession of more than one insurance policy and it comes to processing a claim.
Coordination of benefits (COB) occurs when a patient is covered under more than one insurance plan. This process lets your patients get the benefits they
Coordination of Benefits (COB) is when two insurance plans work together to pay claims for the same person. This occurs when you or your dependents are
Sometimes two insurance plans work together to pay claims for the same person. That process is called coordination of benefits.
“Coordination of benefits” or “COB” means a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their
COB is our process for ensuring that our members receive full benefits and helping to prevent over-payment for services when a member has coverage from two