Monday, 13 November 2017

Claim

A request for benefits of a plan to be provided or paid is a claim. The benefit claimed may be in the form of—

1. Services (including supplies); 
2. Payment for all or a portion of the expenses incurred;
3. A combination of paragraphs (2)(B)1. and 2.; or
4. An indemnification;

 Claim determination period. This is the period of time, which must not be less than twelve (12) consecutive months over which allowable expenses are compared with total benefits payable in the absence of COB, to determine whether over insurance exists and how much each plan will pay or provide.

1. The claim determination period is usually a calendar year, but a plan may use some other period of time that fits the coverage of the group contract. A person may be covered by a plan during a portion of a claim determination period if that person's coverage starts or ends during the claim determination period.

2. As each claim is submitted, each plan is to determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. That determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period; 

 Coordination of benefits. This is a provision establishing an order in which plans pay their claims;

(4) Rules for Coordination of Benefits— Order of Benefits. 

(A) General. The general order of benefits is as follows:

1. The primary plan must pay or provide its benefits as if the secondary plan(s) did not exist. A plan that does not include a coordination of benefits provision may not take the benefits of another plan as defined in subsection (2)(F) into account when it determines its benefits. There is one (1) exception—a contract holder’s coverage that is designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder; and 

2. A secondary plan may take the benefits of another plan into account only when, under these rules, it is secondary to that other plan.

Tuesday, 7 November 2017

20 CSR 400-2.030 Group Coordination of Benefits

PURPOSE: This rule restricts the use of coordination of benefits provisions in group health insurance plans to those situations where they may be equitably applied

(1) Applicability. The purpose of this rule is to— (A) Permit, but not require, plans to include a coordination of benefits (COB) provision;

(B) Establish an order in which plans pay their claims; 

(C) Provide the authority for orderly transfer of information needed to pay claims promptly; 

(D) Reduce duplication of benefits by permitting a reduction of the benefits paid by a plan where the plan, pursuant to rules established by this rule, does not have to pay its benefits first; 

(E) Reduce claims payment delays; and 

(F) Make all contracts that contain a COB provision consistent with this rule.

(2) Definitions. The following words and terms, when used in this rule, shall have the following meanings unless the context clearly indicates otherwise: 

(A) Allowable or Allowable expense. 
1. Allowable or Allowable expense means the necessary, reasonable and customary item of expense for health care when the item of expense is covered at least in part under any of the plans involved, except where a statute requires a different definition. 

2. Notwithstanding this definition, items of expense under coverages, such as dental care, vision care, prescription drug or hearing- aid programs, may be excluded from the definition of allowable expense. A plan which provides benefits only for any of these items of expense may limit its definition of allowable expenses to like items of expense. 

3. When a plan provides benefits in the form of service, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid. 

4. The difference between the cost of a private hospital room and the cost of a semiprivate hospital room is not considered an allowable expense under this definition unless the patient’s stay in a private hospital room is medically necessary in terms of generally accepted medical practice. 

Wednesday, 1 November 2017

Medicare benefits

However, if the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a dependent of an active employee, the order of benefit determination is:

a. First, benefits of a plan covering a person as an employee, member, or subscriber.

b. Second, benefits of a plan of an active worker covering a person as a dependent. 

c. Third, Medicare benefits.  

(b) Except as stated in paragraph (c), if two or more policies or plans cover the same child as a dependent of different parents: 

1. The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls earlier in a year are determined before the benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls later in that year; but 

2. If both parents have the same birthday, the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which covered the parent for a shorter period of time. 

However, if a policy or plan subject to the rule based on the birthdays of the parents coordinates with an out-of-state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a dependent of a male are determined before those of a policy or plan which covers the person as a dependent of a female and if, as a result, the policies or plans do not agree on the order of benefits, the provisions of the other policy or plan determine the order of benefits. 

(c) If two or more policies or plans cover a dependent child of divorced or separated parents, benefits for the child are determined in this order: 

1. First, the policy or plan of the parent with custody of the child. 

2. Second, the policy or plan of the spouse of the parent with custody of the child. 

3. Third, the policy or 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 if the entity obliged to pay or provide the benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits of that policy or plan are determined first, except with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before the entity has the actual knowledge. 

(d) The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired, or as that employee's dependent, are determined before those of a policy or plan which covers the person as a laid-off or retired employee or as the employee's dependent. If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans do not agree on the order of benefits, this paragraph does not apply. 

(e) If none of the rules in paragraph (a), paragraph (b), paragraph (c), or paragraph

(d) determine the order of benefits, the benefits of the policy or plan which covered an employee, member, or subscriber for a longer period of time are determined before those of the policy or plan which covered the person for the shorter period of time. 

(5) Coordination of benefits is not permitted against an indemnity-type policy, an excess insurance policy as defined in s. 627.635, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy. 

Thursday, 26 October 2017

COB – Coordination of Benefits

Sometimes a patient will have more than one health insurance policy. This could be a patient with Medicare and Medicaid. Medicaid is usually the health care benefit that is billed last. The patient could have Medicare and coverage under the Veterans Administration. The patient could be covered under health care provided as a benefit of employment through their own employer or through their spouses employer. If so, the two insurance companies are required to determine which policy is primary or which is secondary. Cob also includes other factors such as birthdate of parents who is providing healthcare to a child. Some states have laws regulating coordination of benefits.

627.4235 Coordination of benefits.-- 

(1) A group hospital, medical, or surgical expense policy, group health care services plan, or group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses delivered or issued for delivery in this state must contain a provision for coordinating its benefits with any similar benefits provided by any other group hospital, medical, or surgical expense policy, any group health care services plan, or any group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses for the same loss.

(2) A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses issued in this state or issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan which provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment. 

Saturday, 21 October 2017

Assignment of Benefit (AOB)

This is a request sent to the insurance company, signed by the patient or member , requesting that the payment of their health benefit be sent to a person they designate to receive the payment of the health benefit. This request may or may not be honored and accepted by the insurance company depending on the patient’s or member’s health benefit contract or State Law. The patient or member’s health benefit contract may prohibit the assignment of the health benefit payment to anyone. State Law such as in Florida and Louisiana may require the insurance company to honor the Assignment request even if the contract prohibits it. If the Assignment is prohibited, the payment of the health benefit will be sent to the patient or member. The requires the provider to bill the patient or member. State Assignment of Benefit Laws can be referenced on the American College of Emergency Physician (ACEP) website: http://www.acep.org/advocacy.aspx?LinkIdentifier=id&id=29364&fid=1018&Mo =No

 Authorization 
Some patients, such as HMO patients may be required to obtain permission or authorization to receive certain services. Sometimes this is inpatient medical care which is when the patient is admitted to the hospital by their primary care provider or an emergency care provider or outpatient visits to an out of network provider.

Balance Bill 
This would be the amount of the debt that the patient owes the doctor after the patient’s commercial insurance company didn’t pay and is being billed for. Balance Billing can be regulated based on the type of health insurance such as Workers Compensation or Medicaid , State law or a provider contract. For example. If the patient has Medicaid and the provider is enrolled with Medicaid, the provider has agreed to accept the Medicaid payment as payment in full. California, Florida and other States have Laws prohibiting the balance billing of an HMO member if the insurance company accepts liability for the claim. In Florida, this law would be FS 641.3154. The contract that the provider has, may have language that states the contracted payment is accepted as payment in full with no patient balance billing.

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