Coordination of Benefits - Private Insurance

HMSA and Another Health Insurance Carrier or Two HMSA Plans

Coordination of benefits (COB) is employed when a member has healthcare coverage from more than one source. HMSA certificates primarily base their coordination of benefits provisions on the order of benefit determination guidelines recommended by the National Association of Insurance Commissioners (NAIC).

The following guidelines apply when a patient has more than one group health benefit plan:

• The plan that covers the patient as the subscriber or policyholder pays first.
• If a child is covered under both the mother's and father's plan, the plan of the parent whose birthday is earlier in the calendar year pays first. (If both parents have the same birthday, the plan with the earlier effective date pays first.)
• In situations where an individual is the subscriber to one policy as an active worker and another policy as an inactive or retired worker, the plan that covers the individual as an active worker is the primary plan.

When none of the general coordination of benefits rules listed above applies, the coverage with the earliest continuous effective date pays first.

Note: Coverage of dependent children of divorced or separated parents is determined according to special rules. A Provider Services Representative should be contacted if there are any questions about these coverage rules.

Claims Filing Information

HMSA and another health insurance carrier

When a patient is covered by HMSA and another plan, additional information about the second plan must be provided to ensure timely and accurate coordination of benefits. Providers should routinely ask members for all insurance cards/information upfront to avoid unnecessary payment delays and/or denials. If you need help determining primacy, please contact our Customer Service department at (808) 948-6330 for assistance.

If HMSA is the primary payer according to the guidelines above, the claim should be filed promptly after services are completed. If HMSA is not the members primary coverage, the claim should be sent to the primary payer first before submitting to HMSA. When payment and/or explanation of benefits (EOB) is received from the primary plan, the claim and EOB should then be submitted to HMSA for coordination of benefits.

For a patient with HMSA coverage plus another health insurance carrier, Block 11d of the CMS 1500 claim form should be marked YES and include the patient's other policy number in Block 9a, along with the required information for Blocks 9, 9b and 9d (other insured's name, date of birth, and insurance plan or program name).

If another health insurance carrier has made any payment for the services being claimed, code Z9014 should be included in Block 24D and the amount should be in Block 24F. The other carrier's payment report does not need to be attached unless the other carrier refused payment or applied a large portion of its payment toward the patient's deductible. For claims submitted electronically, the other carrier's payment amount should be included in the appropriate field.

Two HMSA Plans

For a patient with two HMSA plans, the patient's primary HMSA number should be indicated in Block 1a. Block 11d should be marked YES and the patient's other HMSA number should be included in Block 9a, along with the required information for Blocks 9 and 9b (other insured's name and date of birth). We will verify which HMSA plan is primary and coordinate payment accordingly.

The entire Report to Provider should always be reviewed and all payments should be posted from this report before a claim is submitted for secondary benefits; in most cases such submissions are not necessary. When a member is covered by more than one HMSA plan, our claims processing system is able to show the correct allocation of benefits under the appropriate plan. For example, if a primary-plan payment of 80 percent of the eligible charge is reflected on the report, a secondary-plan payment of the remaining portion of the eligible charge is generally shown on the following week's Report to Provider.

In this situation, a notation directly beneath the claim entry for the primary payment indicates additional benefits are being processed by the member's secondary plan. When this notation appears, another claim should not be submitted. HMSA must first complete the processing of the member's secondary benefits.

If your Report to Provider does not indicate that the primary claim is being reprocessed for secondary payment, please contact us so that we can research why a secondary claim was not created.

Benefit Payment

When HMSA is the member's secondary insurance carrier, the benefits payable under the secondary plan, when combined with the benefits paid under the primary plan, will not be more than 100 percent of HMSA's eligible charge. However, the following items will be subtracted from any benefits due:

• Unpaid deductibles from this plan.
• Benefit reductions imposed by the primary plan.
• Payments made by the primary plan.

In addition, the following limitations are applied when HMSA is the secondary carrier:

• Secondary benefits may only be paid for services that are covered under the secondary plan and meet HMSA's criteria for medical appropriateness.
• When a claim is processed for secondary benefits (even if no payment is made), the service for which payment was made by the primary plan will be counted toward the applicable service maximums of the secondary (HMSA) plan. For example, if the primary plan paid for a screening mammogram for a 50-year-old woman at 100 percent of the eligible charge (leaving no balance to be paid by the secondary plan), HMSA will consider the patient's annual service maximum for a routine screening mammogram to have been used under the secondary (HMSA) plan.
• Payment made by the member's secondary plan may not exceed the amount that would have been made had the plan been the member's only plan.

Revision History