How are claims handled for employees with more than one health insurance plan?
Health benefits are coordinated with any other health insurance plan in effect at the time services are rendered, to ensure the total benefits paid by UniCare and any other group health plan do not exceed 100% of the allowable expenses. Order of Benefit Determination follows any existing legislation, whether Commercial insurance or Medicare. Members are responsible for providing the plan with details regarding other coverage for any & all family members, so claims can be coordinated appropriately. The member’s enrollment form asks for information about any other group coverage for which the member or any other family members may be eligible. Claims analysts use this information to coordinate benefits between other insurance carriers and UniCare. It is also used to identify the carrier that has the primary responsibility for covering medical services.
Health benefits are coordinated with any other health insurance plan in effect at the time services are rendered, to ensure the total benefits paid by UniCare and any other group health plan do not exceed 100% of the allowable expenses. The member’s enrollment form asks for information about any other group coverage for which the member or any other family members may be eligible. Claims analysts use this information to coordinate benefits between other insurance carriers and UniCare. It is also used to identify the carrier that has the primary responsibility for covering medical services.
A42. Blue Cross’ claims processing system is programmed to check information submitted on a claim and review the member’s membership profile to verify if other coverage exists, and identify a COB situation. Once a year, members are sent a questionnaire inquiring if other coverage exists. This information is loaded into the system in order to process claims correctly. Additionally, if a claim is received and there is indication of other coverage unknown to us, we pend the claim and send another questionnaire to the member asking for the COB information.
If the member, the member’s spouse, or the member’s dependents have duplicate coverage under another BCBSGA group program, any other group medical expense coverage, or any local, state or governmental program, (except school accident insurance coverage and Medicaid) then benefits payable under the plan will be coordinated with the benefits payable under the other program. BCBSGA’s liability in coordinating will not be more than 100% of the usual, customary and reasonable (UCR) amount or the contracted amount.
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