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Get 100 percent coverage up to the eligible Reasonable and Customary amount by coordinating with another benefit plan

Wednesday, October 9, 2013
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Get More from Your Benefits, Lowering your out-of-pocket costs

Coordination of benefits (COB) can save you out-of-pocket expenses

Sometimes you might have benefit coverage under more than one extended health plan or even more than one health benefits provider. For example, your plan might be through Pacific Blue Cross and your spouse's plan through another insurer.

In these cases, the patient can submit the expense under both plans to get up to 100 percent of the eligible Reasonable and Customary amount of their expense covered. This is called coordination of benefits.

With coordination of benefits, you claim first with the plan you are a member of, then you claim any amount that was not reimbursed with the second plan.

If you and your spouse both pay premiums to participate in a benefit plan, you may be tempted to save on payroll deductions by opting out of the plan that pays the smaller percentage. However, coordinating the benefits provided by each plan can save you money, in most cases providing coverage up to 100 percent of the eligible Reasonable and Customary amount of their expense. Saving you from out-of-pocket expenses related to health care cost is what your benefit plan is supposed to do.

Pacific Blue Cross follows the Canadian Life and Health Insurance Association’s (CLHIA) Coordination of Benefits Guideline

Pacific Blue Cross is a member of the Canadian Life and Health Insurance Association (CLHIA). Standard Pacific Blue Cross plans, along with other insurers who are members of CLHIA, follow procedures which are set out in the Canadian Life and Health Insurance Association’s Coordination of Benefits (COB) Guideline. This Guideline gives insurance companies a consistent set of rules to follow (e.g., which plan pays first, how benefits are calculated and how to coordinate health care or dental payments from all available group plans) so claims are processed in the same way when an individual makes a claim to more than one group plan either as the plan member or a dependent. This practice fosters consistency within the industry, ensuring fairness and equality to members and plan sponsors.

According to the guideline, coordination of benefits reimbursement means that claims are paid to PBC’s Reasonable and Customary (R&C) limit, regardless if one or more carriers are involved. If another benefit plan has already reimbursed a claim up to the PBC R&C limit, no additional reimbursement will be eligible under your plan.

Understanding coordination of benefits

Let's say John's benefit plan covers his acupuncture treatment ($100*) at 50 percent co-insurance. John's wife Kathy has a plan that covers the acupuncture treatment at 80 percent. If John only had his own coverage, he would only receive reimbursement for half of the service fee he claimed under his benefit plan. But because he is also a dependent on his wife's plan, he can claim the unpaid portion with the other benefit plan.

* PBC’s R&C limit for this acupuncture treatment is $100

John's quite happy because as a result he was able to receive back 100% of his health care expense by coordinating the benefits. And his back is feeling better too.

Which plan should you claim under first?

In the example above, let's assume both plans are provided by Pacific Blue Cross. John should submit a claim for his acupuncture treatment under his plan first (he would get $50 back assuming it's a covered benefit, he had satisfied his deductible and the Acupuncturist was registered).

John should then resubmit the remainder to Kathy's plan (he would receive the remaining $50 – again if this was covered under her plan).

If John's plan was with another benefit provider, and Kathy's was with Pacific Blue Cross, after he submits the claim to his plan, he would resubmit the photocopied receipt and the Explanation of Benefits statement from his benefit provider with his claim for reimbursement from his Blue Cross coverage.

Simple rules—always submit the claim first to the benefit plan that belongs to whoever received treatment and to the other benefit provider once you have received your claim payment and statement from the first.

If both plans are with Pacific Blue Cross and if we have the most up-to-date information on file, you can submit one claim only and it will automatically be considered under both plans.

Coordinating benefits for your dependent children:

Admittedly, things can get a little confusing when you are submitting claims for your children.

For dependent children, the plan that pays first is determined by the birth date (Month & Day) of the parents:

  • If your birth date is prior to your spouse's in the calendar year, your plan is the first payer and your children's expenses must be claimed through your own plan first.
  • If your spouse's birth date is prior to yours in the calendar year, then your spouse's plan is the first payer for your dependent children. In that case, you must pay for their expenses, take photocopies, and submit the original receipts to your spouse's plan first.
  • If your spouse has a pay direct drug card, and your spouse is the first payer, your children's prescription drugs can be submitted electronically using your spouse's pay direct card. The pharmacist will issue a paper receipt showing the amount that the plan pays. Any remaining balance can be submitted to Pacific Blue Cross using a paper claim form* along with the photocopied receipts and the explanation of benefits from the other plan, for reimbursement.

Keep us up to date and we'll help you coordinate benefits

Ensure that you indicate both of the plan numbers when completing the claim form. The primary plan should be indicated on the top left hand corner of the claim form and the secondary policy and identification number should be indicated at the bottom of the claim form, where it asks "Do you or any other dependant have any other insurance to cover these benefits?"

Remember to also update your service providers if they prepare or submit claims to us on your behalf.

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