Coordination of Benefits
Last Updated on October 06, 2026
- If a member carries insurance through more than one insurer, Security Health Plan will coordinate the benefits to ensure maximum coverage without duplication of payments.
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Order of benefit determination
- Most insurance plans or other payers, including group and direct pay plans, should pay as primary to Medicaid Managed Care.
- Exceptions: Family Health Center (FHC) – Medicaid Managed Care should pay as primary to FHC
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- The provider must submit claims to the primary carrier before submitting to Security Health Plan. After a claim is processed by the primary carrier, a claim should be submitted to Security Health Plan along with either the primary carrier’s Explanation of Benefits (EOB) or their electronic payment/denial information. The affiliated provider must submit the claim within 365 days from the date of service or within 60 days from the date on the other insurance EOB, whichever is later.
- When a patient has a VA authorization, any services related to that authorization should not be billed to the member’s personal health insurance. The provider is responsible to bill the related services to the appropriate Third-Party Administrator documented on the referral.
- If the provider fails to comply or is unaware of the primary insurance carrier, claims for which Security Health Plan is secondary will be denied using ANSI code 22. This denial reason will print on the provider’s reimbursement statement.
- If a primary insurance is discovered after charges have been processed by Security Health Plan, and the primary insurance makes payment, the provider may have an overpayment. The provider is required to submit a copy of the original claim and a copy of the EOB from the primary insurance. Claims will be processed based on the primary insurance payment. The adjustment will be reflected on the provider’s reimbursement statement.
- If Security Health Plan discovers a primary insurance carrier after charges have been processed, Security Health Plan will reverse its original payment. The adjustment will be reflected on the provider’s statement using ANSI 22.
- If the primary insurance denied the claim for lack of information or if the primary insurance has not responded to the provider within 45 days, the provider must submit an inquiry to the primary carrier (and/or member, as needed) regarding the disposition of the claim. If no answer within 30 days of the inquiry, the provider can submit the claim to Security Health Plan. If adequate documentation (i.e. non-compliant packet) is received with the claim showing the provider's attempts to resolve the issue with the primary insurance within 365 days from the DOS or 60 days from the date of the primary denial, whichever is later, Security Health Plan will process the Medicaid claim.
- Adequate documentation includes three documented attempts by phone or letter to the member or primary insurance within a reasonable timeframe. Documentation could include the provider’s account documentation notes, copies of billing history, copies of letters to the member or primary insurance, telephone call logs, etc.
- If the primary insurance denies a claim with Claim Adjustment Group Code “CO” (financial responsibility for the unpaid charge is assigned to the provider as a contractual obligation), as a secondary or tertiary payer, Security Health Plan will also deny these charges using Claim Adjustment Reason Code (CARC) 276 (services denied by the prior payer are not covered by this payer). Affiliated providers may not balance bill members for CARC 276 denials.
- If the provider has any questions regarding coordination of benefits, call 1-800-548-4831 Monday through Friday, between 8 a.m. and 4:30 p.m. or email shpcob-mfld@Sanfordhealth.org
If a Security Health Plan member has Medicare or another insurance, follow these instructions to ensure a claim will be processed correctly and in a timely manner.
- Complete information must be on the CMS 1500 claim or UB-04 claim, or must be included with the electronic claim.
- On the CMS 1500 claim, box 11d should be checked “Yes” if there is any other insurance information. If box 11d is checked “Yes”, boxes 9a – 9d on the CMS 1500 claim must be completed with the other insurance information.
- On the UB-04 claim, field 50 should be completed if there is any other insurance information.
- On electronic CMS 1500 or UB-04 claims, loop 2320 should include other insurance information.
- EOBs or electronic payment/denial information must accompany each CMS 1500 claim and UB-04 claim if other primary insurance is indicated on the claim.