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Medica Administrative Manual  > Billing and Reimbursement > Coordination of Benefits

Coordination of Benefits

Coordination of Benefits (COB) provisions allow health plans to coordinate their reimbursements for services provided to a patient. Medica will coordinate reimbursement with another Medica benefit plan, a non-Medica benefit plan or health insurance policy as well as with Medicare.

When reimbursements are coordinated, combined reimbursements from the various carriers will be limited to 100% of allowable charges. This is designed to eliminate over insurance or duplication of benefits.

Please notify Medica when a member has multiple insurance coverage by:

  • Indicating a primary carrier on the CMS-1500 claim or UB-04 claim form.
  • Having the member notify Member Service if there is a primary carrier and Medica is secondary.

Medica follows the National Association of Insurance Commissioners (NAIC) COB guidelines in determining primary and secondary payers.


COB Calculations

Medica uses the following methods for calculating COB benefits:

  • Come Out Whole
  • Non-Duplication of Benefits

Come Out Whole

The primary plan pays its normal plan benefits without regard to the existence of any other coverage. The secondary plan pays the difference between the primary plan's allowable expense and the amount paid by the primary plan, provided this difference does not exceed the normal plan benefits which would have been payable had no other coverage existed.

Non-Duplication of Benefits

The insured's secondary insurance plan pays the difference, if any, between the amount paid by the primary plan and the amount that would have been paid by the secondary plan if it had been primary, not to exceed the member liability remaining after the primary has paid, then subject to normal plan benefits thereafter as secondary.

Notes

  • We follow the member's plan document to determine which COB method to use.

Assignment of Benefits with Medicare

A participating provider who "accepts Medicare's assignment" agrees to the amount that Medicare allows for a particular procedure. Although the member may have a Medicare copayment, coinsurance or deductible to meet for the service(s), the difference between the billed charge and the allowed amount will not be billed to the patient.

If the Provider does not accept assignment:

  • Medicare will still reimburse only 80 percent of allowable charges (once the deductible has been met). The provider can collect from the member the 20 percent coinsurance and the difference between the billed amount and the allowable amount determined by Medicare.
  • Medicare reimburses the member. The member is then responsible for reimbursing the provider. The Explanation of Medicare Benefit (EOMB), addressed to the member, indicates that the member is responsible for the difference between the billed and approved amounts and that this could have been avoided if the claims had been assigned.

Medica Coordination Benefits with Medicare for assigned claims:

  • When services are provided by a Medica contracted provider, Medica coordinates up to Medicare's approved amount.
  • There may be exceptions for members who are covered by Medicare as well as covered by a plan contracted through the Department of Human Services (DHS).
  • Typically, this means that Medica will be responsible for the member's Medicare copayment, coinsurance and deductible amounts stated on the EOMB.
  • Sometimes, due to state statutes, Medica reimburses charges that Medicare denies; as an example, some preventive services are covered. If Medicare denies the charge and Medica would normally reimburse the charge as a covered service, then Medica would reimburse those charges in addition to the copayments, coinsurance and deductibles due. If Medica would normally deny the charge as an ineligible service (Medicare also denied), then Medica would not reimburse those charges.

Medica Coordination Benefits with Medicare for unassigned claims:

  • For all levels of claims, Medica coordinates up to fee maximum schedules. Generally, this means that Medica will be responsible for the member's Medicare copayment, coinsurance or deductible.
  • There may be exceptions for members who are covered by Medicare as well as covered by a plan contracted through the Department of Human Services (DHS).
  • Medica only reimburses copayments, coinsurance and deductibles. Medica does not reimburse contract adjustments on Medicare bills.

 


Medicaid

Medica’s Minnesota Health Care Programs will always be the last payer when a member has more than one insurance policy.

The Tort Recovery Program is a Department of Human Services (DHS) requirement. If a Medicaid plan paid primary, but another Third Party Insurance payer should have been responsible, Medicaid will recover the overpayment.

If a provider has made three unsuccessful attempts at collecting the primary carrier’s payment, they can submit proof of the three previous claim submissions to have the claim denial overturned. Additional questions can be directed to the Provider Service Center at 1-800-458-5512.



Helpful Information for COB with Medicare and Medicaid Products

See additional COB information for Medica’s Medicare and Medicaid products.



REV 12/2021

Date: 1/28/2023 5:54:33 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01