Coordination of Benefits (COB). The Contractor shall actively pursue, collect and retain all monies available from all available resources for services to Members under this Contract except where the amount of reimbursement the Contractor can reasonably expect to receive is less than estimated cost of recovery. Cost effectiveness of recovery is determined by, but not limited to, time, effort, and capital outlay required in performing the activity. The Contractor shall specify the threshold amount or other guidelines used in determining whether to seek reimbursement from a liable third party, or describe the process by which the Contractor determines seeking reimbursement would not be cost effective. The Contractor shall provide the guidelines to the Department for review and approval. COB collections are the responsibility of the Contractor or its Subcontractors. Subcontractors must report COB information to the Contractor. Contractor and Subcontractors shall not pursue collection from the Member but directly from the third party payer. The Contractor shall only recoup payments to providers if the third party payer is Medicare. Access to Covered Services shall not be restricted due to COB collection. The Contractor shall maintain records of all COB collections. The Contractor must be able to demonstrate that appropriate collection efforts and appropriate recovery actions were pursued. The Department has the right to review all billing histories and other data related to COB activities for Members. The Contractor shall seek information on other available resources from all Members. In order to comply with CMS reporting requirements, the Contractor shall submit a monthly COB Report for all member activity which the Department or its agent shall audit no less than every six (6) months. Additionally, Contractor shall submit a report that includes subrogation collections from auto, homeowners, or malpractice insurance, etc.
Coordination of Benefits (COB). The activities involved in determining Medicaid benefits when a member has coverage through an individual, entity, insurance, or program that is liable to pay for health care services.
Coordination of Benefits (COB). If an Eligible Person or Eligible Dependent is covered for Dental Services or Benefits by another third party provider’s contract, arrangement, or insurance carrier, the Plan’s liability for payment will be determined as follows:
Coordination of Benefits (COB). Coordinating with other valid coverage for payment of Covered Services. All other group and nongroup or direct-pay insurance policies or health care benefits (excluding Indian Health Service and Medicaid coverage) that provide payments for medical or other care services constitute other valid coverage.
Coordination of Benefits (COB). The coordination of benefits provision of this policy applies when a person has health care coverage under more than one Plan as defined below. The order of benefit determination rules govern the order in which each Plan pays a claim for benefits. • The Plan that pays first is the “Primary Plan”. The Primary Plan must pay benefits in accordance with its policy terms without regard to the possibility that another Plan may cover some expenses. • The Plan that pays after the Primary Plan is the “Secondary Plan.” The Secondary Plan may reduce the benefits it pays so that payments from all Plans do not exceed 100% of the total Allowable Expense. The HMO will provide access to Covered Services first and determine liability later. Definitions Unique to Coordination of Benefits In addition to the defined terms in the Definitions section of this policy, the following definitions apply to this provision: Plan: Plan means This Coverage and/or Other Plan.
Coordination of Benefits (COB) is a program which determines which plan or insurance policy will issue primary payment when two insurance companies cover the same benefits. If one of the plans is a Medicare Health Plan, Federal Law establishes which plan is the Primary Payer. It is the process of determining the respective 2016 TSA Policy and Procedure Template. Hardcopies of this document are considered uncontrolled, for the latest version please refer to Compliance 360 or contact Compliance Department through: XXXXxxxxxxxxx@xxxxxxxxxxxx.xxx CONFIDENTIAL TREATMENT REQUESTED. INFORMATION FOR WHICH CONFIDENTIAL TREATMENT HAS BEEN REQUESTED IS OMITTED AND MARKED WITH “[***]”. AN UNREDACTED VERSION OF THE DOCUMENT HAS ALSO BEEN FURNISHED SEPARATELY TO THE SECURITIES AND EXCHANGE COMMISSION AS REQUIRED BY RULE 24B-2 UNDER THE SECURITIES EXCHANGE ACT OF 1934, AS AMENDED. FINAL EXECUTION VERSION TSA P&P #: CL-009 Page 2 of 10 responsibilities of two or more health care insurance plans that have financial responsibility over a medical claim.
Coordination of Benefits (COB). This section tells you how other health insurance you may have affects your coverage under this Plan.
