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Provider Manual

Order of Benefit Determination

Last Updated on August 28, 2018

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 subscriber vs. non-group: If a group and non-group plan exist, primacy will be coordinated with the other carrier.

Medical assistance: All private health insurance plans are considered primary. Benefits must be billed and processed prior to consideration by medical assistance.