Coordination of Benefits

by Jessica Guenard-Valiquette on March 25, 2011

What is Coordination of Benefits?

Coordination of benefits is a practice used to minimize the potential of fraudulent claims so that insurance claims are not paid multiple times when someone is insured under more than one insurance plan.

When health care benefits are coordinated  the insured is fully covered, but not covered to excess. The need for coordination of benefits arises when spouses are each covered for health and/or dental benefits through their respective employers. Coordination of benefits prevents someone who is insured on multiple plans from submitting full claims to each plan and then pocketing the excess cash.

Employees who choose to have family coverage through both employers must state on their enrolment that they have benefits already and which carrier (insurance company, group number and certificate number if possible).

How do plan members file claims?

 

Each person is required to make their claim with their company’s insurance carrier first. Once the initial claim has been processed, then whatever amount is not covered by their insurance can then be claimed under their spouse’s plan. 

Since original receipts should be sent to their first company (or at least kept in case they are required), a copy of the claim confirmation form from the first insurance company should be sent to the second insurer.  This shows the second insurer how much the first insurer covered.

What about claims for dependent children?

Children’s claims are sent to the insurance company that covers the parent whose birthday is first on the calendar, regardless of the year of birth.  If Mr. Smith’s birthday is March 11 and Mrs. Smith’s birthday is June 9th, then claims are sent to Mr. Smith’s company first.

If both parents birthdays occur in the same month, then the parent whose birthday falls earliest in the month will submit to their insurer first.  If both parents birthdates occur on the same day than the alphabetical rule will apply. The parent whose first name begins with an earlier letter of the alphabet submit the claims to their insurer first.  For example, if Bill and Mary share the same birthday, then Bill will submit to his insurer first, and Mary will submit second.

 As always, if you have any questions, please do not hesitate to contact us.  We are happy to hear from you.

 

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