Coordination of Benefits - Vision

Important Note:

Effective January 1, 2022, HMSA has partnered with EyeMed for routine vision services for the following lines of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87, and HMSA Plan for Postal Service Employees. 

Non-routine vision services remain under our medical benefit and will be processed as such.

For more information, please visit EyeMed at www.eyemedinfocus.com.

Determining Order of Benefits for Multiple Plans

HMSA coordinates benefits for members covered by more than one health insurance plan. When determining which plan is primary, coordination of benefits (COB) provisions are based on 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, regardless of age, pays first. (If both parents have the same birthday, the plan with the earlier effective date pays first.)
• If a member subscribes to more than one plan, the plan with the earlier effective date is primary.

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

Coverage of dependent children of divorced or separated parents

Coverage of dependent children of divorced or separated parents is determined according to special rules. Please call a Provider Teleservice Representative at 1-808-948-6330 on Oahu or 1-800-790-4672 from the Neighbor Islands if you have questions about coordination of benefits.

Claims Filing Information - HMSA and Another Health Insurance Carrier

When a patient is covered by HMSA and another plan, it is important to provide additional information about the second plan to ensure timely and accurate coordination of benefits.

If you believe HMSA will be the primary payer according to the guidelines above, please file the claim promptly after services are completed. If you think HMSA is the secondary payer, please send the claim to the primary payer first.

For a patient covered by HMSA and another health insurance carrier, please mark YES in Block 11d of the CMS 1500 claim form 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).

Reporting another carrier's primary payment - paper claims

If you are filing a paper claim and another health insurance carrier has made any payment for the services you are claiming, please include code Z9014 in Block 24D and indicate the amount in Block 24F. It is not necessary to attach the other carrier's payment report unless the other carrier refused payment or applied a large portion of its payment toward the patient's deductible.

Reporting another carrier's primary payment - Electronic Media Claims (EMC)

If you are filing your claim electronically, your HIPAA compliant software will include a field where you can record the other carrier's payment.

Claims Filing Information - Two HMSA Plans

For a patient with two HMSA plans, please indicate the patient's primary HMSA number in Block 1a. Mark YES in Block 11d and include the patient's other HMSA number 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 process the claim under both plans in order of primacy.

When a member has two HMSA vision plans, each of which permits one fully paid eye exam, lenses or contact lenses benefit per calendar year, HMSA will only pay for one vision exam, lenses or contact lenses per calendar year.

Always review your entire Report to Provider and post all payments from this report before deciding to submit a claim for secondary benefits. In most cases, both primary and secondary plan payments generally are shown on the same Report to Provider. Sometimes the member's secondary payment will be reflected on a following week's Report to Provider. In this situation, a message on the Report to Provider indicates additional benefits are being processed by the member's secondary plan, and no further submission is necessary.

If your Report to Provider does not indicate that the claim is being reprocessed for secondary payment and you find it necessary to resubmit a claim for secondary benefits, do not use HMSA's locally assigned code Z9014 to reflect payment by the primary (HMSA) plan. This code only represents payment by a carrier other than HMSA, and its use will delay the processing of your claim.

For instructions on resubmitting a claim for secondary benefits, see Claims Filing Highlights - Vision and Verifying Claim Status and Resubmission of Processed Claims (CMS-1500).

Examples

Please refer to Coordination of Benefits - Examples for specific details regarding payment coordination for an HMSA member who is covered by more than one vision plan.

Claims Filing Information - Benefit Payment

• When HMSA is the member's secondary insurance carrier, benefits will generally be coordinated up to 100 percent of the 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 benefit payment.
  • 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.
  • 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