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.
Order of Benefit Determination
- No coordination of benefits provision: A plan automatically becomes primary if it contains no coordination of benefits provision.
- Employee, member or subscriber: The benefits of a plan that covers a person as an employee, member or subscriber are determined before those of a plan that covers the person as a spouse or dependent of an employee, member or subscriber.
- Dependent child/parents NOT separated or divorced: For dependent children, the benefits of the plan of the parent whose birthday falls earlier in the calendar year (month and day) are determined to be primary. If both parents have the same birthday, primacy is determined by which plan has covered the parent longer.
- Dependent child/separated or divorced parents: If two or more plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:
- First, the plan of the parent with custody of the child
- Then, the plan of spouse of the parent with custody of the child
- Finally, the plan of the parent not having custody of the child
However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the plan of parent has actual knowledge of those terms, the benefits of that plan are determined first.
Also, primary benefits for the dependent child shall be determined according to the benefits of the plan of the parent whose birthday falls earlier in the calendar year (month and day) if:
- The specific terms of a court decree state that the parents have joint custody of the child and do not specify that one parent has responsibility for the child’s health care expenses, or
- If the court decree states that both parents shall be responsible for the health care needs of the child but gives physical placement of the child to one parent, and the entities obligated to pay or provide the benefits of the respective parents’ plans have actual knowledge of those terms.
- Subscriber under two plans: If the subscriber is the same person under two plans, the primary plan is the one in effect the longest.
- Group vs. non-group: If a group and non-group plan exist, primacy will be coordinated with the other carrier.
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 180 days from the date of service or within 180 days of the primary payer’s statement, whichever is later, unless the provider’s contract states otherwise.
- 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 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 denies a claim because of lack of information, Security Health Plan will also deny.
- 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, call1-800-548-4831 Monday through Friday, between 8:00 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.