How Coordination of Benefits Sample Clauses

How Coordination of Benefits. (COB) Works. The services and benefits provided under this Contract are not intended to and do not duplicate any benefit to which Members are entitled under any health plan, program or policy which may be subject to COB. The amount of our payment, if any, when we coordinate benefits under this Part, is based on whether or not AvMed is the primary payer. When AvMed is not primary, our payment for Covered Services may be reduced so that total benefits under all your plans will not exceed 100% of the total reasonable expenses actually incurred for Covered Services. For purposes of this Part, in the event you receive Covered Services from a Participating Provider, ‘total reasonable expenses’ will mean the amount we are obligated to pay to the provider pursuant to the applicable provider agreement we have with such provider, or if there is no such provider agreement, the amount we are obligated to pay the provider pursuant to state or federal law. When AvMed is not the primary payer, and the primary payer’s payment exceeds XxXxx’s contracted amount, no payment will be made for such services.
Sample 1Sample 2Sample 3See All (47)
AutoNDA by SimpleDocs

Related to How Coordination of Benefits

  • Coordination of Benefits The coordination of benefits (COB) provision applies when a Member has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to 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. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Member is covered by more than one health benefit plan, and the Member does not know which is the primary plan, the Member or the Member’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Member contacts is responsible for working with the other plan to determine which is primary and will let the Member know within 30 calendar days. All health plans have timely claim filing requirements. If the Member or the Member’s provider fails to submit the Member’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Member experiences delays in the processing of the claim by the primary health plan, the Member or the Member’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Member is covered by more than one health benefit plan, the Member or the Member’s provider should file all the Member’s claims with each plan at the same time. If Medicare is the Member’s primary plan, Medicare may submit the Member’s claims to the Member’s secondary carrier.

  • Retention of Benefits Union leave under the following four (4) sections will be unpaid. The Employer will maintain regular pay and xxxx the Union for the costs of the employee’s salary and benefits. If the Union member is part-time or casual, and the leave is greater than their normal work hours, the Employer will pay the employee for the full length of the leave requested by the Union. The Employer will xxxx the Union for these days as noted above. The Union will pay these invoices within twenty-eight (28) days. Union leave is not unpaid leave for the purposes of Article 22.02 [i.e. such leave will not affect the employee’s benefits, seniority or increment anniversary date].

  • Duplication of Benefits Grantee shall not carry out any of the activities under this Agreement in a manner that results in a prohibited duplication of benefits as defined by Section 312 of the Xxxxxx X. Xxxxxxxx Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155) and in accordance with Section 1210 of the Disaster Recovery Reform Act of 2018 (division D of Public Law 115-254; 132 Stat. 3442), which amended section 312 of the Xxxxxx X. Xxxxxxxx Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155). In consideration of Grantee’s receipt or the commitment of CRF funds by Florida Housing, Grantee hereby assigns to Florida Housing all of Grantee’s future rights to reimbursement and all payments received from any grant, subsidized loan or any other reimbursement or relief program related to the basis of the calculation of the portion of the funds committed to the Grantee under this Agreement and determined to be a Duplication of Benefits (DOB). Any such funds received by the Grantee shall be referred to herein as “additional funds.” Grantee agrees to immediately notify Florida Housing of the source and receipt of additional funds received by the Grantee that are determined to be a DOB. Grantee agrees to reimburse Florida Housing for any additional funds received by Grantee if such additional funds are determined to be a DOB by Florida Housing, the Federal awarding agency or an auditing agency.

  • Payment of Benefits a) In computing the amount of disability benefits, disability will be considered as starting from the first day of disability; however, an employee must be certified by a medical practitioner for the disability within the first three days of disability. In the event that the employee is not certified within the first three days, disability will be considered as starting two complete days prior to the day that the employee is actually certified by a medical practitioner.

Time is Money Join Law Insider Premium to draft better contracts faster.