Common use of Coordination of Benefits Clause in Contracts

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurance. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s), or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in this Agreement.

Coordination of Benefits. ILS Community Network or Managed Care 12.1 Plan will coordinate benefits in accordance with Mandates and in accordance with its any other health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so plan (as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(sdefined below) with the primary liability (including the Medicare program, if the recipient is eligible covering a Member which allows for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Employer Group and Members agree to provide Plan is not Enrollee's primary payor, Provider's compensation by Managed Care with such information and assistance as Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurancemay require to enable it to coordinate benefits. 4.3.1 Provider payment 12.2 The rules establishing the order of benefit determination between this Agreement and any other health plan covering the Member on whose behalf a claim is made are set forth below. None of these rules will not be delayed due serve as a barrier to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due Member's first receiving Benefits under this Agreement less from Plan. Further, in no event shall a Member be required, as a result of these rules, to pay any amount other than as required by this Agreement for any Benefit. 12.3 The term "health plan" as used in this Agreement is defined to include any health care service plan, nonprofit hospital service plan, insurer, group practice, individual practice or other prepayment plan, employee benefit plan, employer organization plan, union welfare plan, labor-management trustee plan, and any other governmental or private program which provides or arranges for the amount payable or to be paid by the other payor(s)provision of, or (iii) pays, reimburses, or indemnifies for the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payorcost of, ILS Community Network any health care services, whether pursuant to statutory requirement or Managed Care provision or otherwise. 12.4 If another health plan does not provide for coordination of benefits, Plan shall pay Provider always have primary responsibility for the amount provision of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in Benefits covered by this Agreement. 12.5 For those health plans which provide for coordination of benefits, the following rules establishing the order of benefits determination shall apply: 12.5.1 The benefits of a health plan which covers the person on whose expenses claim is based other than as a Dependent shall be determined before the benefits of a health plan which covers such person as a Dependent, except that if the person is also a Medicare beneficiary and as a result of the rules established for the Medicare Program and implementing regulations, Medicare is (a) secondary to the health plan covering the person as a dependent; and (b) primary to the health plan covering the person as other than a Dependent (e.g., retired employee), then the benefits of the health plan covering the person as a Dependent are determined before those of the health plan covering that person as other than a Dependent. 12.5.2 Except for cases of a person for whom a claim is made as a Dependent Child whose parents are separated or divorced, the benefits of a health plan which covers the person on whose expenses claim is based as a Dependent of a person whose date of birth, excluding year of birth, occurs earlier in a Calendar Year, shall be determined before the benefits of a health plan which covers such person as a Dependent of a person whose date of birth, excluding year of birth, occurs later in a Calendar Year. If either health plan does not have the provision of this Section regarding Dependents, which results either in each health plan determining its benefits before the other or in each health plan determining its benefits after the other, the provisions of this Section shall not apply, and the rule set forth in the health plan which does not have the provisions of this Section shall determine the order of benefits. 12.5.3 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced and the parent with custody of the Child has not remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody of the Child shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.4 In the case of a person for whom claim is made as a Dependent Child whose parents are divorced and the parent with custody of the Child has remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody shall be determined before the benefits of a health plan which covers that Child as a Dependent of the stepparent, and the benefits of a health plan which covers the Child as a Dependent of the stepparent shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.5 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced, where there is a court decree which would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the Child, then, notwithstanding Sections 12.5.3 and 12.5.4, above, the benefits of a health plan which covers the Child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other health plan which covers the Child as a Dependent Child. 12.5.6 If a health plan does not have a provision regarding laid-off or retired employees, which results in each health plan determining its benefits after the other, then the rule under Section 12.5.5 shall not apply. 12.5.7 If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another health plan, the following shall be the order of benefit determination: (a) first, the benefits of a health plan covering the person as an employee, member, or subscriber, or as that persons' Dependent; and (b) second, the benefits under continuation coverage. If the other health plan does not have the rules described above, and if, as a result, the health plans do not agree on the order of benefits, the rule under this Section shall be ignored. 12.5.8 When rules 12.5.1 through 12.5.7 do not establish an order of benefit determination, the benefits of a health plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a health plan which has covered such person the shorter period of time.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as Pursuant to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. N.J.A.C. 11:4-28 et seq., Participating Provider agrees to bill other payor(scooperate fully with and provide assistance to Payor for the purpose of Coordination of Benefits (“COB”) with respect to other entities that are primary payors or otherwise have payment responsibility for services or supplies furnished to Members. COB payments shall be processed consistent with the following examples: 7.3.1 Where both the primary liability (including and secondary Plans pay Provider on the Medicare programbasis of contractual fee schedules and Provider furnishes services or supplies and is a participating provider of the primary and secondary Plans, if the recipient is eligible for allowable expense shall be considered to be the contractual fee of the primary Plan. The primary Plan shall pay the benefit it would have paid without regard to the existence of other coverage, and the secondary Plan shall pay any deductible, coinsurance or co-payment for health care which the Member is liable up to the amount the secondary Plan would have been required to pay if primary and provided that the total amount received by the Provider from the primary Plan, the secondary Plan and the Member does not exceed the contractual fee of the primary Plan. In no event shall the Member be responsible for any payment in excess of the co-payment, coinsurance or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills deductible for the same secondary Plan. 7.3.2 Where the primary Plan pays a benefit on the basis of the usual and customary rate (“UCR”), and the secondary Plan pays on the basis of a contractual fee schedule, and Provider furnishes services or supplies and is a participating provider of the secondary Plan, the primary Plan shall pay the benefit it would have paid without regard to Managed Care the existence of other coverage. The secondary Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than pay the difference between the amount Provider’s billed charges and the benefit paid by the primary payor(s) Plan up to the amount the secondary Plan would have paid if primary. The payment of the secondary Plan shall be applied first toward satisfaction of the Member’s liability for any co-payment, coinsurance or deductible of the primary Plan. The Member shall only be liable for the co-payment, deductible and coinsurance under the secondary Plan if the Member has no liability for a co-payment, coinsurance or deductible under the primary Plan and the applicable rate under this Agreement, total payments by both the primary and secondary Plans are less any applicable Co-payments or Co-insurance. 4.3.1 Provider payment will than the Provider’s billed charges. The Member shall not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination liable for any billed charges in excess of the sum of the benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s)primary Plan, or (iii) the difference between allowed billed charges and the amount benefits paid by the other payor(s). In secondary Plan, and the event Medicare is co- payment, deductible or coinsurance paid by the Member under either the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contractsecondary Plans. In no event will ILS Community Network shall Member be responsible for any payment in excess of the co- payment, coinsurance or Managed Care deductible of the secondary Plan. 7.3.3 Where the primary Plan pays Provider on the basis of a contractual fee schedule, and the secondary Plan pays for the particular benefit on the basis of the UCR, and Provider furnishes services or supplies and is a participating provider of the primary Plan, the allowable expense considered by the secondary Plan shall be the contractual fee of the primary Plan. The secondary Plan shall pay a monetary any co-payment, coinsurance or deductible for which the Member is liable under the terms and conditions of the primary Plan up to the amount which when combined with payments from that the other payor(s) exceeds the contracted rate provided in this Agreementsecondary Plan would have been required to pay if primary.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as Pursuant to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. N.J.A.C. 11:4-28 et seq., Participating Provider agrees to bill other payor(scooperate fully with and provide assistance to Payor for the purpose of Coordination of Benefits (“COB”) with respect to other entities that are primary payors or otherwise have payment responsibility for services or supplies furnished to Members. COB payments shall be processed consistent with the following examples: 7.3.1 Where both the primary liability (including and secondary Plans pay Provider on the Medicare programbasis of contractual fee schedules and Provider furnishes services or supplies and is a participating provider of the primary and secondary Plans, if the recipient is eligible for allowable expense shall be considered to be the contractual fee of the primary Plan. The primary Plan shall pay the benefit it would have paid without regard to the existence of other coverage, and the secondary Plan shall pay any deductible, coinsurance or co-payment for health care which the Member is liable up to the amount the secondary Plan would have been required to pay if primary and provided that the total amount received by the Provider from the primary Plan, the secondary Plan and the Member does not exceed the contractual fee of the primary Plan. In no event shall the Member be responsible for any payment in excess of the co- payment, coinsurance or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills deductible for the same secondary Plan. 7.3.2 Where the primary Plan pays a benefit on the basis of the usual and customary rate (“UCR”), and the secondary Plan pays on the basis of a contractual fee schedule, and Provider furnishes services or supplies and is a participating provider of the secondary Plan, the primary Plan shall pay the benefit it would have paid without regard to Managed Care the existence of other coverage. The secondary Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than pay the difference between the amount Provider’s billed charges and the benefit paid by the primary payor(s) Plan up to the amount the secondary Plan would have paid if primary. The payment of the secondary Plan shall be applied first toward satisfaction of the Member’s liability for any co-payment, coinsurance or deductible of the primary Plan. The Member shall only be liable for the co-payment, deductible and coinsurance under the secondary Plan if the Member has no liability for a co-payment, coinsurance or deductible under the primary Plan and the applicable rate under this Agreement, total payments by both the primary and secondary Plans are less any applicable Co-payments or Co-insurance. 4.3.1 Provider payment will than the Provider’s billed charges. The Member shall not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination liable for any billed charges in excess of the sum of the benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s)primary Plan, or (iii) the difference between allowed billed charges and the amount benefits paid by the other payor(s). In secondary Plan, and the event Medicare is co-payment, deductible or coinsurance paid by the Member under either the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contractsecondary Plans. In no event will ILS Community Network shall Member be responsible for any payment in excess of the co-payment, coinsurance or Managed Care deductible of the secondary Plan. 7.3.3 Where the primary Plan pays Provider on the basis of a contractual fee schedule, and the secondary Plan pays for the particular benefit on the basis of the UCR, and Provider furnishes services or supplies and is a participating provider of the primary Plan, the allowable expense considered by the secondary Plan shall be the contractual fee of the primary Plan. The secondary Plan shall pay a monetary any co-payment, coinsurance or deductible for which the Member is liable under the terms and conditions of the primary Plan up to the amount which when combined with payments from that the other payor(s) exceeds the contracted rate provided in this Agreementsecondary Plan would have been required to pay if primary.

Coordination of Benefits. ILS Community Network “Coordination of benefits” is the procedure used to pay dental care expenses when a person is covered by more than one plan. Company follows rules established by Florida law to decide which plan pays first and how much the other plan must pay. The objective is to make sure the combined payments of all plans are no more than your actual bills. When you or Managed Care Plan your family members are covered by another group plan in addition to this one, we will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and follow Florida coordination of benefit guidelinesrules to determine which plan is primary and which is secondary. Provider agrees You must submit all bills first to bill other payor(s) with the primary liability (including the Medicare program, plan. The primary plan must pay its full benefits as if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all you had no other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefitscoverage. If Managed Care Plan is the primary plan denies the claim or does not Enrollee's pay the full bill, you may then submit the balance to the secondary plan. Company pays for dental care only when you follow our rules and procedures. If our rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use. PLANS THAT DO NOT COORDINATE Company will pay benefits without regard to benefits paid by the following kinds of coverage. -- Individual (not group) policies or contracts unless they contain a Coordination of Benefits Provision. -- Medicaid -- Group hospital indemnity plans which pay less than $100 per day -- School accident coverage -- Some supplemental sickness and accident policies HOW COMPANY PAYS AS PRIMARY PLAN When we are primary, we will pay the full benefit allowed by your contract as if you had no other coverage. HOW COMPANY PAYS AS SECONDARY PLAN When we are secondary, our payments will be based on the balance left after the primary payor, Provider's compensation by Managed Care Plan or its delegee shall be plan has paid. We will pay no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurance. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s), or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contractthat balance. In no event will ILS Community Network we pay more than we would have paid had we been primary. --We will pay only for dental care expenses that are covered by Company. --We will pay only if you have followed all of our procedural requirements, including (care obtained from or Managed Care Plan arranged by your primary care physician, precertification, etc.). --We will pay a monetary amount no more than the “allowable expenses” for the dental care involved. If our allowable expense is lower than the primary plan’s, we will use the primary plan’s allowable expense. That may be less than the actual bill. WHICH PLAN IS PRIMARY? To decide which when combined with payments from plan is primary, we have to consider both the coordination provisions of the other payor(s) exceeds plan and which member of your family is involved in a claim. The Primary Plan will be determined by the contracted rate provided in this Agreementfirst of the following which applies: 1. Non-coordinating Plan If you have another group plan which does not coordinate benefits, it will always be primary.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as All Benefits under this Certificate are subject to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and a‌ coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare programbenefits provision, if the recipient applicable, that is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees designed to provide Managed Care maximum coverage, but not result in payment of more than 100 percent of the total fee for a given treatment. Coordination of Benefits (“COB”) applies to This Plan or its delegee with relevant information it when a Member has collected from Enrollees regarding coordination dental benefits under more than one plan. The objective of benefits. If Managed Care Plan COB is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be to make sure the combined payments of the plans are no more than your actual dental bills. COB rules establish whether This Plan’s Benefits are determined before or after another plan’s benefits. A Plan is any of the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreementfollowing that provides benefits or services for, less any applicable Coor because of, medical or dental care or treatment: ♦ Group insurance or group-payments or Co-insurance. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has type coverage, other than with ILS Community Network whether insured or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s)uninsured. ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this AgreementThis includes pre-payment group practice, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s)individual practice coverage. It does not include school accident-type coverage, blanket, franchise, individual, automobile, or homeowner coverage. ♦ Coverage under a governmental plan or coverage required or provided by law. This does not include a state plan under Medicaid (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payorTitle XIX, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductibleGrants to States for Medical Assistance Programs, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the United States Social Security Act, as amendedamended from time to time). It also does not include any plan when, subject by law, its benefits are excess to those of any private insurance program or other non-governmental program. You must submit your bills to the benefit limits and applicable rates primary plan first. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies your Claim or does not pay the full bill, you may then submit the remainder of the applicable bill to the secondary plan. Allowable Expenses are necessary, reasonable, and customary items of expense for health care when the item of expense is covered at least in part by one or more plans covering the person for whom the Claim is made. Total benefits contractpaid must be equal to 100 percent of necessary medical expenses covered by both plans. In no event However, This Plan is not required to pay for an item, service, or benefit which is not a part of This Plan’s Contract. Which Plan is Primary? To decide which plan is primary, Delta Dental will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from consider both the COB provisions of the other payor(s) exceeds plan and the contracted rate provided in this Agreementrelationship of the Member to This Plan’s Subscriber, as well as other factors. The primary plan is determined by the first of the following rules that applies: 1. Non-coordinating Plan If you have another plan that does not coordinate benefits, it will always be primary.

Coordination of Benefits. ILS Community Network PCP agrees that payment for Covered Services provided to Members is subject to coordination with any other benefits payable or Managed Care Plan will coordinate paid to or for a Member. Such benefits include, but are not limited to, any group insurance coverage, contract, prepayment plan or governmental program and any claims that may give rise to compensation to a Member from a third party, including, without limitation, workers' compensation and automobile insurance. VISTA shall be subrogated to all rights of recovery of a Member against any person or entity for such PCP October 4, 2004 benefits or payments as permitted under applicable law and this Agreement. PCP shall use its best efforts to determine whether a Member has any benefits as described above or whether a third party may be responsible for payment. PCP shall assist VISTA in coordination of benefits by (i) requiring a Member so covered to sign all necessary documents to give effect to this Section 2.6; and (ii) signing any other document and providing any other information or records so requested by VISTA at no cost to VISTA. Unless otherwise required by law, PCP shall not be entitled to reimbursement by any third party for Covered Services rendered to Members, including, Medicare intermediaries or carriers, and all sums recovered pursuant to this Section 2.6 shall be retained by VISTA. Unless required by law or the applicable VISTA Coverage Plan, in the event VISTA is the primary carrier, payments made by VISTA to PCP plus allowed Co-Payments, Deductibles and Co-Insurance shall be deemed payment in full for all services rendered by PCP hereunder. In the event VISTA is the secondary carrier (except in the case of Medicare or where otherwise required by law), VISTA shall pay for all services rendered to Members in accordance with Mandates this Agreement and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is law that were not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(scarrier; provided, however, that the combined payments made by the primary and secondary carriers shall not exceed one hundred percent (100%) and of the applicable rate compensation due PCP by VISTA under Schedule 4.1 of this Agreement. If VISTA is the secondary carrier to Medicare, less any applicable VISTA's liability shall be limited to Deductible and Co-payments or Co-insuranceInsurance amounts, unless otherwise required by federal law. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s), or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in this Agreement.

Coordination of Benefits. ILS Community Network or Managed Care 12.1 Plan will coordinate benefits in accordance with Mandates and in accordance with its any other health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so plan (as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(sdefined below) with the primary liability (including the Medicare program, if the recipient is eligible covering a Member which allows for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Employer Group and Members agree to provide Plan is not Enrollee's primary payor, Provider's compensation by Managed Care with such information and assistance as Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurancemay require to enable it to coordinate benefits. 4.3.1 Provider payment 12.2 The rules establishing the order of benefit determination between this Agreement and any other health plan covering the Member on whose behalf a claim is made are set forth below. None of these rules will not be delayed due serve as a barrier to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due Member's first receiving Benefits under this Agreement less from Plan. Further, in no event shall a Member be required, as a result of these rules, to pay any amount other than as required by this Agreement for any Benefit. 12.3 The term "health plan" as used in this Agreement is defined to include any health care service plan, nonprofit hospital service plan, insurer, group practice, individual practice or other prepayment plan, employee benefit plan, employer organization plan, union welfare plan, labor-management trustee plan, and any other governmental or private program which provides or arranges for the amount payable or to be paid by the other payor(s)provision of, or (iii) pays, reimburses, or indemnifies for the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payorcost of, ILS Community Network any health care services, whether pursuant to statutory requirement or Managed Care provision or otherwise. 12.4 If another health plan does not provide for coordination of benefits, Plan shall pay Provider always have primary responsibility for the amount provision of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in Benefits covered by this Agreement. 12.5 For those health plans which provide for coordination of benefits, the following rules establishing the order of benefits determination shall apply: 12.5.1 The benefits of a health plan which covers the person on whose expenses claim is based other than as a Dependent shall be determined before the benefits of a health plan which covers such person as a Dependent, except that if the person is also a Medicare beneficiary and as a result of the rules established for the Medicare Program and implementing regulations, Medicare is (a) secondary to the health plan covering the person as a Dependent; and (b) primary to the health plan covering the person as other than a Dependent (e.g., retired employee), then the benefits of the health plan covering the person as a Dependent are determined before those of the health plan covering that person as other than a Dependent. 12.5.2 Except for cases of a person for whom a claim is made as a Dependent Child whose parents are separated or divorced, the benefits of a health plan which covers the person on whose expenses claim is based as a Dependent of a person whose date of birth, excluding year of birth, occurs earlier in a Calendar Year, shall be determined before the benefits of a health plan which covers such person as a Dependent of a person whose date of birth, excluding year of birth, occurs later in a Calendar Year. If either health plan does not have the provision of this Section regarding Dependents, which results either in each health plan determining its benefits before the other or in each health plan determining its benefits after the other, the provisions of this Section shall not apply, and the rule set forth in the health plan which does not have the provisions of this Section shall determine the order of benefits. 12.5.3 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced and the parent with custody of the Child has not remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody of the Child shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.4 In the case of a person for whom claim is made as a Dependent Child whose parents are divorced and the parent with custody of the Child has remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody shall be determined before the benefits of a health plan which covers that Child as a Dependent of the stepparent, and the benefits of a health plan which covers the Child as a Dependent of the stepparent shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.5 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced, where there is a court decree which would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the Child, then, notwithstanding Sections 12.5.3 and 12.5.4, above, the benefits of a health plan which covers the Child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other health plan which covers the Child as a Dependent Child. 12.5.6 If a health plan does not have a provision regarding laid-off or retired employees, which results in each health plan determining its benefits after the other, then the rule under Section 12.5.5 shall not apply. 12.5.7 If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another health plan, the following shall be the order of benefit determination: (a) first, the benefits of a health plan covering the person as an employee, member, or subscriber, or as that persons' Dependent; and (b) second, the benefits under continuation coverage. If the other health plan does not have the rules described above, and if, as a result, the health plans do not agree on the order of benefits, the rule under this Section shall be ignored. 12.5.8 When rules 12.5.1 through 12.5.7 do not establish an order of benefit determination, the benefits of a health plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a health plan which has covered such person the shorter period of time.

Coordination of Benefits. ILS Community Network or Managed Care 12.1 Plan will coordinate benefits in accordance with Mandates and in accordance with its any other health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so plan (as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(sdefined below) with the primary liability (including the Medicare program, if the recipient is eligible covering a Member which allows for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Employer Group and Members agree to provide Plan is not Enrollee's primary payor, Provider's compensation by Managed Care with such information and assistance as Plan or its delegee shall be no more than the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insurancemay require to enable it to coordinate benefits. 4.3.1 Provider payment 12.2 The rules establishing the order of benefit determination between this Agreement and any other health plan covering the Member on whose behalf a claim is made are set forth below. None of these rules will not be delayed due serve as a barrier to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due Member's first receiving Benefits under this Agreement less from Plan. Further, in no event shall a Member be required, as a result of these rules, to pay any amount other than as required by this Agreement for any Benefit. 12.3 The term "health plan" as used in this Agreement is defined to include any health care service plan, nonprofit hospital service plan, insurer, group practice, individual practice or other prepayment plan, employee benefit plan, employer organization plan, union welfare plan, labor-management trustee plan, and any other governmental or private program which provides or arranges for the amount payable or to be paid by the other payor(s)provision of, or (iii) pays, reimburses, or indemnifies for the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payorcost of, ILS Community Network any health care services, whether pursuant to statutory requirement or Managed Care provision or otherwise. 12.4 If another health plan does not provide for coordination of benefits, Plan shall pay Provider always have primary responsibility for the amount provision of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in Benefits covered by this Agreement. 12.5 For those health plans which provide for coordination of benefits, the following rules establishing the order of benefits determination shall apply: 12.5.1 The benefits of a health plan which covers the person on whose expenses claim is based other than as a Dependent shall be determined before the benefits of a health plan which covers such person as a Dependent, except that if the person is also a Medicare beneficiary and as a result of the rules established for the Medicare Program and implementing regulations, Medicare is (a) secondary to the health plan covering the person as a dependent; and (b) primary to the health plan covering the person as other than a Dependent (e.g., retired employee), then the benefits of the health plan covering the person as a Dependent are determined before those of the health plan covering that person as other than a Dependent. 12.5.2 Except for cases of a person for whom a claim is made as a Dependent Child whose parents are separated or divorced, the benefits of a health plan which covers the person on whose expenses claim is based as a Dependent of a person whose date of birth, excluding year of birth, occurs earlier in a Calendar Year, shall be determined before the benefits of a health plan which covers such person as a Dependent of a person whose date of birth, excluding year of birth, occurs later in a Calendar Year. If either health plan does not have the provision of this Section regarding Dependents, which results either in each health plan determining its benefits before the other or in each health plan determining its benefits after the other, the provisions of this Section shall not apply, and the rule set forth in the health plan which does not have the provisions of this Section shall determine the order of benefits. 12.5.3 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced and the parent with custody of the Child has not remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody of the Child shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.4 In the case of a person for whom claim is made as a Dependent Child whose parents are divorced and the parent with custody of the Child has remarried, the benefits of a health plan which covers the Child as a Dependent of the parent with custody shall be determined before the benefits of a health plan which covers that Child as a Dependent of the stepparent, and the benefits of a health plan which covers the Child as a Dependent of the stepparent shall be determined before the benefits of a health plan which covers the Child as a Dependent of the parent without custody. 12.5.5 In the case of a person for whom claim is made as a Dependent Child whose parents are separated or divorced, where there is a court decree which would otherwise establish financial responsibility for the medical, dental or other health care expenses with respect to the Child, then, notwithstanding Sections 12.5.3 and 12.5.4, above, the benefits of a health plan which covers the Child as a Dependent of the parent with such financial responsibility shall be determined before the benefits of any other health plan which covers the Child as a Dependent Child. 12.5.6 If a health plan does not have a provision regarding laid-off or retired employees, which results in each health plan determining its benefits after the other, then the rule under Section 12.5.5 shall not apply. 12.5.7 If a person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another health plan, the following shall be the order of benefit determination: (a) first, the benefits of a health plan covering the person as an employee, member, or subscriber, or as that persons' Dependent; and (b) second, the benefits under continuation coverage. If the other health plan does not have the rules described above, and if, as a result, the health plans do not agree on the order of benefits, the rule under this Section shall be ignored. 12.5.8 When rules 12.5.1 through 12.5.7 do not establish an order of benefit determination, the benefits of a health plan which has covered the person on whose expenses claim is based for the longer period of time shall be determined before the benefits of a health plan which has covered such person the shorter period of time.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as All Benefits under this Certificate are subject to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and a coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare programbenefits provision, if the recipient applicable, that is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees designed to provide Managed Care maximum coverage, but not result in payment of more than 100 percent of the total fee for a given treatment. Coordination of Benefits (“COB”) applies to This Plan or its delegee with relevant information it when a Member has collected from Enrollees regarding coordination dental benefits under more than one plan. The objective of benefits. If Managed Care Plan COB is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be to make sure the combined payments of the plans are no more than your actual dental bills. COB rules establish whether This Plan’s Benefits are determined before or after another plan’s benefits. A Plan is any of the difference between the amount paid by the primary payor(s) and the applicable rate under this Agreementfollowing that provides benefits or services for, less any applicable Coor because of, medical or dental care or treatment: ♦ Group insurance or group-payments or Co-insurance. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties. In cases where a Enrollee has type coverage, other than with ILS Community Network whether insured or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s)uninsured. ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this AgreementThis includes pre-payment group practice, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s)individual practice coverage. It does not include school accident-type coverage, blanket, franchise, individual, automobile, or homeowner coverage. ♦ Coverage under a governmental plan or coverage required or provided by law. This does not include a state plan under Medicaid (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payorTitle XIX, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductibleGrants to States for Medical Assistance Programs, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the United States Social Security Act, as amendedamended from time to time). It also does not include any plan when, subject by law, its benefits are excess to those of any private insurance program or other non-governmental program. You must submit your bills to the benefit limits and applicable rates primary plan first. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies your Claim or does not pay the full xxxx, you may then submit the remainder of the applicable xxxx to the secondary plan. Allowable Expenses are necessary, reasonable, and customary items of expense for health care when the item of expense is covered at least in part by one or more plans covering the person for whom the claim is made. Total benefits contractpaid must be equal to 100 percent of necessary medical expenses covered by both plans. In no event However, This Plan is not required to pay for an item, service, or benefit which is not a part of This Plan’s Contract. Which Plan is Primary? To decide which plan is primary, Delta Dental will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from consider both the COB provisions of the other payor(s) exceeds plan and the contracted rate provided in this Agreementrelationship of the Member to This Plan’s Subscriber, as well as other factors. The primary plan is determined by the first of the following rules that applies: 1. Non-coordinating Plan If you have another plan that does not coordinate benefits, it will always be primary.

Coordination of Benefits. ILS Community Network or Managed Care Plan will coordinate benefits in accordance with Mandates and in accordance with its health care benefit contracts. Provider The PROVIDER shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and submit an itemized billing statement for coordination of benefit guidelinesbenefits (COB) billing purposes detailing the daily revenue code and daily physician HCPC service code to fulfill PAYOR’S State of Michigan reporting and COB requirements. Provider agrees to bill other payor(s) Any dual eligible CONSUMER with the primary liability (including the Medicare program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall a deductible/coinsurance will be no more than the difference between the amount paid by the primary payor(sPAYOR in total up to the agreed upon payment amount for the billed service(s) identified in this agreement after all other payments, contractual adjustments, and the applicable rate under this Agreement, less any applicable Coco-payments payment, CONSUMER pay, or Co-insurance. 4.3.1 Provider Medicaid Spend Down amounts have been deducted. The PAYOR shall only be responsible for and limit reimbursement to the PROVIDER for any amount less than the agreed upon amount for the billed service(s) identified in this agreement. In cases where third party coverage reimbursement exceeds the agreed upon amount for the billed service(s) identified in this agreement, no additional payment will be authorized the PAYOR. In all cases where the PAYOR is the secondary PAYOR, the PROVIDER shall submit an Explanation of Benefits (EOB) from the primary insurance coverage carrier along with the claim for service reimbursement to the PAYOR. Claims: All claims should be received by the PAYOR within ninety (90) days from the date of discharge should be free and clear of any problems and able to be processed for payment consideration without obtaining additional information from the PROVIDER of the service or a third party. It does not be delayed due to ILS Community Network include a claim from a PROVIDER who is under investigation for fraud or Managed Care Plan recovery efforts from Third Partiesabuse, or a claim under review for medical necessity. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid Clean Claim is not submitted by the other payor(s)PROVIDER within one (1) year of the CONSUMER’s discharge, or (iii) the difference PAYOR shall not be required to authorize payment, unless otherwise mutually agreed upon in advance between allowed billed charges the PROVIDER and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in this AgreementPAYOR.

Coordination of Benefits. ILS Community Network (COB) 1. Cost effectiveness of recovery is determined by, but not limited to time, effort, and capital outlay required to perform the activity. The HMO upon request of the Department, must be able to specify the threshold amount or Managed Care Plan will other guidelines used in determining whether to seek reimbursement from a liable third party, or describe the process by which the HMO determines seeking reimbursement would not be cost effective. 2. To ensure compliance, the HMO must maintain records of all COB collections and report them to the Department on a quarterly basis. The COB report must be submitted in the format specified in Addendum VIII, B HMOs 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 enrollees. HMOs must seek from all enrollees’ information on other available resources. HMOs must also seek to coordinate benefits in accordance with Mandates before claiming reimbursement from the Department for the AIDS and in accordance with its health care benefit contracts. Provider shall cooperate with Managed Care Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare programventilator dependent enrollees: a. Other available resources may include, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with but are not limited to, all other state or federal medical care programs that are primary to Medicaid, group or individual health insurance, ERISAs, service benefit plans, the insurance of absent parents who may have insurance to pay medical care for spouses or minor enrollees, and subrogation/worker’s compensation collections. b. Subrogation collections are any recoverable amounts arising out of the settlement of personal injury, medical malpractice, product liability, or Worker’s Compensation. State subrogation rights have been extended to HMOs under s. 49.89(9), Act 31, Laws of 1989. After attorneys’ fees and Federal requirements in this regard) prior to submitting bills for expenses have been paid, the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Plan is not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than HMO will collect the difference between the full amount paid by on behalf of the primary payor(s) and the applicable rate under this Agreement, less any applicable Co-payments or Co-insuranceenrollee. 4.3.1 Provider payment will not be delayed due to ILS Community Network or Managed Care Plan recovery efforts from Third Parties3. In cases where a Enrollee has coverage, other than with ILS Community Network or Managed Care Plan, which requires or permits coordination of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (iSection 1912(b) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s), or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject Act must be construed in a beneficiary-specific manner. The purpose of the distribution provision is to permit the beneficiary to retain TPL benefits to which he or she is entitled except to the benefit limits extent that Medicaid (or the HMO on behalf of Medicaid) is reimbursed for its costs. The HMO is free, within the constraints of state law and applicable rates this Contract, to make whatever case it can to recover the costs it incurred on behalf of its enrollee. It can use the Medicaid fee schedule, an estimate of what a capitated physician would charge on a FFS basis, the value of the applicable care provided in the market place, or some other acceptable proxy as the basis of recovery. However, any excess recovery, over and above the cost of care (however the HMO chooses to define that cost), must be returned to the beneficiary. HMOs may not collect from amounts allotted to the beneficiary in a judgment or court-approved settlement. The HMO must follow the practices outlined in the Department’s Casualty Recovery Manual. 4. COB collections are the responsibility of the HMO or its subcontractors. Subcontractors must report COB information to the HMO. HMOs and subcontractors must not pursue collection from the enrollee, but directly from the third party payer. Access to medical services must not be restricted due to COB collection. 5. The following requirement applies if the Contractor (or the Contractor’s parent firm and/or any subdivision or subsidiary of either the Contractor’s parent firm or of the Contractor) is a health care benefits contractinsurer (including, but not limited to, a group health insurer and/or health maintenance organization) licensed by the Wisconsin Office of the Commissioner of Insurance and/or a third-party administrator for a group or individual health insurer(s), health maintenance organization(s), and/or employer self-insurer health plan(s): a. Throughout the contract term, these insurers and third-party administrators must comply in full with the provision of subsection 49.475 of the Wisconsin Statutes. In no event will ILS Community Network or Managed Care Plan pay Such compliance must include the routine provision of information to the Department in a monetary amount which when combined manner and electronic format prescribed by the Department and based on a monthly schedule established by the Department. The type of information provided must be consistent with payments the Department’s written specifications. b. Throughout the contract term, these insurers and third-party administrators must also accept and properly process post payment xxxxxxxx from the other payor(s) exceeds Department’s fiscal agent for health care services and items received by Wisconsin Medicaid enrollees. 6. If at any time during the contracted rate provided contract term any of the insurers or third party administrators fail, in this Agreement.whole or in part, to adhere to the requirements of subsection 5, a or 5, b above, the Department may take the remedial measures specified in Article XX, X, 0 xxx Xxxxxxx XX, X, 0, a.

Coordination of Benefits. ILS Community Network or Managed Care The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. The order of benefit determination rules govern the order in which each Plan will coordinate pay a Claim for benefits. The Plan that pays first is called the Primary Plan. The Primary Plan must pay benefits in accordance with Mandates and in accordance with its health care benefit contractspolicy terms without regard to the possibility that another Plan may cover some expenses. Provider shall cooperate with Managed Care The Plan or its delegee so as to allow Managed Care Plan to evaluate possible subrogation claims and properly coordinate benefits in accordance with that pays after the requirements of applicable laws and coordination of benefit guidelines. Provider agrees to bill other payor(s) with the primary liability (including the Medicare program, if the recipient is eligible for payment for health care or related services from another insurer or person and comply with all other State and Federal requirements in this regard) prior to submitting bills for the same services to Managed Care Plan or its delegee. Provider also agrees to provide Managed Care Plan or its delegee with relevant information it has collected from Enrollees regarding coordination of benefits. If Managed Care Primary Plan is the Secondary Plan. When This Plan is secondary, it may reduce its benefits so that the total benefits paid or provided by all Plans for any Claim are not Enrollee's primary payor, Provider's compensation by Managed Care Plan or its delegee shall be no more than the difference between total Allowable Expenses. In determining the amount to be paid for any Claim, the Secondary plan will calculate the benefits it would have paid in the absence of other health care coverage and apply that calculated amount to any Allowable Expense under its Plan that is unpaid by the Primary Plan. The Secondary Plan may then reduce its payment by the amount so that, when combined with the amount paid by the primary payor(s) and Primary plan, the applicable rate under this Agreementtotal benefits paid or provided by all Plans for the Claim do not exceed the total Allowable Expense for that Claim. In addition, less the Secondary Plan shall credit to its plan deductible any applicable Co-payments or Co-insuranceamounts it would have credited to its deductible in the absence of other health care coverage. 4.3.1 Provider payment A. WITHIN THIS PART, THE FOLLOWING DEFINITIONS APPLY: 1. Allowable Expense: A health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not be delayed due to ILS Community Network or Managed Care covered by any Plan recovery efforts from Third Partiescovering the person is not an Allowable Expense. In cases where addition, any expense that a Enrollee has coverage, other than provider by law or in accordance with ILS Community Network or Managed Care Plan, which requires or permits coordination a contractual agreement is prohibited from charging a Covered Person is not an Allowable Expense. The amount of benefits from a third party payor in addition to ILS Community Network or Managed Care Plan, ILS Community Network or Managed Care Plan will coordinate its benefits with such other payor(s). ILS Community Network or Managed Care Plan will pay the lesser of (i) the amount due under this Agreement, or (ii) the amount due under this Agreement less the amount payable or to be paid any benefit reduction by the other payor(s)Primary Plan because a Covered Person has failed to comply with the Plan provisions is not an Allowable Expense. Examples of these types of plan provisions include second surgical options, or (iii) the difference between allowed billed charges precertification of admissions, and the amount paid by the other payor(s). In the event Medicare is the primary payor, ILS Community Network or Managed Care Plan shall pay Provider the amount of deductible, Co- Insurance and/or other plan benefits which are not Covered Services under Title XVIII of the Social Security Act, as amended, subject to the benefit limits and applicable rates of the applicable health care benefits contract. In no event will ILS Community Network or Managed Care Plan pay a monetary amount which when combined with payments from the other payor(s) exceeds the contracted rate provided in this Agreementpreferred provider arrangements.