Coordination of Benefits - Facilities

Hospital billing for members with multiple health plans can be a challenging process. This section outlines HMSA's coordination of benefits methodology and claims filing instructions.

Dual Coverage/Dual Membership

HMSA coordinates benefits for members covered by more than one health insurance plan. When determining which plan is primary, coordination of benefits provisions are based on guidelines recommended by the National Association of Insurance Commissioners (NAIC).

HMSA as Primary Payer

As primary payer, HMSA makes payment to health care facilities based on the eligible charge, as specified in the facility's Participating Agreement with HMSA.

HMSA as Secondary Payer

When it is determined that HMSA is the secondary payer and the primary payer is a plan other than Medicare, payment for the facility is calculated as follows.

Payment Policy

As a secondary payer, HMSA's payment to the hospital, combined with the primary carrier's payment, does not exceed the lesser of:

• 100 percent of the HMSA eligible charge; or
• The amount payable by the primary plan plus any deductible and copayment the member would owe if the primary plan were the member's only coverage

Any payment by HMSA as secondary payer will not exceed the amount that would have been paid for covered services received by the member had the HMSA plan been the member's only coverage.

Note: The provider may not bill the member for additional payment for covered services after HMSA has coordinated benefits.

Members with Dual HMSA Plans

If a member has two HMSA private business plans (e.g., Preferred Provider Plan and Health Plan Hawaii), HMSA automatically coordinates benefits and issues payment under both member numbers. If a facility believes it has not received full payment for members with two HMSA plans, the billing staff should take the steps below before submitting claims for secondary benefits.

1. Read the Report to Provider carefully
   The Report to Provider (RTP) indicates when secondary benefits were considered, even if they were not paid. If provisions such as a deductible or noncoverage for certain services limit the secondary plan's payment, the provider should not submit a claim requesting payment of secondary benefits.
   Note: Claims payment may also be verified by using Hawaii Healthcare Information Network (HHIN+).
2. Post all payments
   The provider should post payments from the entire RTP before generating claims for secondary benefits. Benefits paid under the secondary plan may be shown on a different page or on the following week's RTP. Submitting additional claims before posting all payments can result in duplicate claims.
3. Confirm membership eligibility
   If a thorough review of the RTP does not indicate that secondary payment was made for a member, the provider should check member eligibility before creating a claim for secondary benefits. Providers may verify eligibility by:
   • Using HHIN+'s eligibility function
   • Calling HMSA's Membership Connection at 808-948-6244 on Oahu or 1-800-552-8507 from the Neighbor Islands

Secondary benefit payment will be made only if the member had active secondary coverage for medical plan benefits at the time services were rendered.

Revision History