Previous Policy

Claims Process

Summary

This section describes how claims are filed with the plan and how those claims are processed. This section applies to all plan benefits, except benefit provided by the plan's Kaiser option. For claims processed under the Kaiser option, refer to the Kaiser plan booklet.

This section also describes the coordination of benefit method used by this plan. If you or your dependents are covered under another health care plan or Medicare, this plan coordinates benefits with the other plan or Medicare. In the event of an illness or injury caused by another person, this plan contains a third-party liability provision which is explained in detail.

Timely Filing Requirement

Network providers are responsible for timely claims submission. Non-network provider claims should be submitted as soon as possible but not later than 12 months from the date of service or the claim will be denied and the expenses will not be covered. All information necessary to process or reprocess the claim must be submitted within this 12-month deadline. Please note: The plan pays primary to Medicaid so if you are also eligible for Medicaid you must notify your provider of your plan coverage. Claims for which Medicaid would be secondary must also be submitted as soon as possible but not later than 12 months from the date of service. Claims for which Medicaid would be secondary submitted by a provider more than 12 months from the date of service will be denied, even if the provider was not aware of the plan coverage.

Coordination of Benefits

Coordination of Benefits with Dollar Bank Eligibility

Coordination of benefits (COB) is a way of determining the order in which benefits are paid and the amounts which are payable when an individual is covered under more than one health care plan or Medicare. Coordination of benefits determines which plan pays first, which plan pays second and which plan pays third. It also ensures that the total payments from all plans do not exceed 100 percent of the total covered charge. All benefits of this plan are subject to coordination of benefits, except time loss benefits, life insurance, and accidental death and dismemberment benefits.

Coordination of Benefits with Non-medicare Retiree Coverage

If you are eligible to receive benefits from a primary plan, the amount of benefits that would have been payable by the primary plan will be subtracted from this plan's payable benefits, even if the claim was not filed with the primary plan.

Coordination of Benefits with Medicare Retiree Coverage

If you are eligible to receive benefits from a primary plan, the amount of benefits that would have been payable by the primary plan will be subtracted from this plan's payable benefits, even if the claim was not filed with the primary plan.

Definitions Applicable to Coordination of Benefits

To understand coordination of benefits, it is important to know the meanings of the following two terms:

"Covered charges" means the charge for a service or supply covered by this plan and incurred while the individual is eligible under this plan. "Covered charges" do not include services or supplies that fall within the exclusionary provisions of this plan even if those services or supplies are recognized as "covered charges" under any of the other plans involved.

"Plan" for purposes of coordination of benefits with this plan means all of the following, even if they do not have their own coordination provisions:

• Group, individual or blanket disability insurance policies and health care service contractor and health maintenance organization agreements issued by insurers, health care service contractors and health maintenance organizations.
• Labor-management trustee plans, labor organization plans, employer organization plans, or employee benefit organization plans.
• Government programs which provide benefits for their own civilian employees or their dependents.
• Group coverage required or provided by any law including Medicare. This does not include workers' compensation.

Rules for Coordination of Benefits

When you are covered by two (2) or more plans, the rules for determining the order of benefit payments are as follows:

1. The primary plan shall pay or provide its benefits as if the secondary plan or plans did not exist.
2. A plan that does not contain a coordination of benefits provision that is consistent with these rules or the NAIC model coordination of benefit rules is always primary. There is one exception: coverage that is obtained by virtue of membership in a group and 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. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide non-network benefits.
3. A plan may consider the benefits paid or provided by another plan only when it is secondary to that other plan.
4. Order of Benefit Determination
   The first of the following rules that describes which plan pays its benefits before another plan is the rule to use:
   1. Non-Dependent or Dependent
      The plan that covers the individual other than as a dependent, for example as an employee, member, subscriber, or retiree, is primary and the plan that covers the individual as a dependent is secondary. However, if the individual is a Medicare beneficiary, and, as a result of the provisions of Title XVIII of the Social Security Act and implementing regulations, Medicare is:
      1. Secondary to the plan covering the individual as a dependent; and
      2. Primary to the plan covering the individual as other than a dependent (e.g., a retired employee),
      then the order of benefits is reversed so that the plan covering the individual as an employee, member, subscriber, or retiree is secondary and the other plan is primary.
   2. Child Covered Under More Than One Plan
      Unless there is a court decree stating otherwise, plans covering a dependent child shall determine the order of benefits as follows:
      1. For a dependent child, whose parents are married or are living together, whether or not they have ever been married:
         1. The plan of the parent whose birthday falls earlier in the calendar year is the primary plan;
         2. If both parents have the same birthday, the plan that has covered the parent longer is the primary plan.
      2. For a dependent child whose parents are divorced or separated or are not living together, whether or not they have ever been married:
         1. If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of the parent has actual knowledge of those terms, that plan is primary. This item shall not apply with respect to any claim determination period or plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision;
         2. If a court decree states one parent is to assume primary financial responsibility for the dependent child but does not mention responsibility for health care expenses, the plan of the parent assuming financial responsibility is primary.
         3. If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of subparagraph (a) of this paragraph shall determine the order of benefits;
         4. If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of subparagraph (a) of this paragraph shall determine the order of benefits; or
         5. If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the dependent child are as follows:
            1. The plan covering the custodial parent;
            2. The plan covering the custodial parent's spouse;
            3. The plan covering the noncustodial parent;
            4. The plan covering the noncustodial parent's spouse;
            5. The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; and
            6. If both parents have the same birthday, the plan that has covered the parent longer is the primary plan.
      3. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under subparagraph (a) or (b) of this paragraph as if those individuals were parents of the child.
         
      4. 1. For a dependent child who has coverage under either or both parents' plans and also has his or her own coverage as a dependent under a spouse's plan, the rule in paragraph (5) applies.
         2. In the event the dependent child's coverage under the spouse's plan began on the same date as the dependent child's coverage under either or both parents' plans, the order of benefits shall be determined by applying the birthday rule in subparagraph (a) to the dependent child's parent(s) and the dependent's spouse.
   3. Active Employee or Inactive or Laid-Off Employee
      1. The plan that covers a person as an active employee that is, an employee who is neither laid off nor retired or as a dependent of an active employee is the primary plan. The plan covering that same person as a retired or laid-off employee or as a dependent of a retired or laid-off employee is the secondary plan.
      2. If the other plan does not have this rule and as a result, the plans do not agree on the order of benefits, this rule is ignored.
   4. COBRA Coverage
      If an individual whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the plan covering the individual as an employee, member, subscriber, or retiree (or as that individual's dependent) is primary and the continuation coverage is secondary. This rule does not apply if the rule under D(1) can determine the order of benefits. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule is ignored.
   5. Longer or Shorter Length of Coverage
      The plan that covered the person as an employee, member, policyholder, subscriber or retiree longer is the primary plan and the plan that covered the person the shorter period of time is the secondary plan.
   6. If the preceding rules do not determine the order of benefits, the allowable expenses must be shared equally between the plans meeting the definition of plan. In addition, this plan will not pay more than it would have paid had it been the primary plan.

Coordination of Benefits with Medicare

Medicare has guidelines which determine when it is the primary or secondary payer for an individual who has another health care plan and under what circumstances. This plan will follow Medicare guidelines when you or your dependent is covered by Medicare.

Generally, anyone age 65 or older is entitled to Medicare coverage. Anyone under age 65 who is entitled to Social Security Disability Income benefits is also entitled to Medicare coverage (generally after a waiting period).

If the total amount of benefits provided by this plan together with the amount of "like benefits" you or your dependent receives or is entitled to receive from Medicare exceeds the actual expenses incurred for such benefits, the benefits provided by this plan will be reduced so that the combined benefits do not exceed the actual expenses of such benefits.

"Like benefits" refers to reimbursement for the cost of services and supplies for which benefits would otherwise be payable under the plan.

If you are an active employee and age 65 or older, this plan is generally your primary plan and Medicare is your secondary plan. You may select Medicare as your primary plan for yourself and your Medicare-eligible spouse. However, if you select Medicare as your primary plan, this plan will not pay any of your medical expenses not paid by Medicare.

If you are a retiree, Medicare is your primary plan and any benefits from this plan are only available after Medicare has processed your claim.

If your coverage in this plan is based upon COBRA because you are no longer working, and you are entitled to Medicare based on age or disability, Medicare is primary and this plan is secondary.

If you have Medicare based on end-stage renal disease, this plan is primary during the first 30 months of Medicare eligibility or entitlement and after 30 months Medicare is primary.

In order to receive full plan benefits, a retiree and dependent spouse must enroll in Medicare Part A and Part B when eligible for that coverage. Even if COBRA is elected in lieu of Retiree Coverage you are expected to enroll in Medicare. This plan does not provide benefits for amounts that would have been reimbursed by Medicare Part A or Part B if you fail to enroll.

Participants, retirees and dependents who have end-stage renal disease should also enroll in Medicare when eligible.

Facility of Payment

A payment made under another health care plan may include an amount which should have been paid under this plan. If it does, this plan may pay that amount to the organization that made the payment. The amount is treated as though it were a benefit paid under this plan and this plan will not pay that amount again.