In her keynote speech, Matthews discussed the NAIC adoption of the Coordination of Benefits (COB) Model Regulation in 1971. COB provision to certain benefits, such as dental benefits, coordinating only with similar benefits, and may apply another COB provision to coordinate other benefits. endobj 4 0 obj Coordination of Benefits (COB) clause that allows the benefits of one policy to be coordinated with the benefits of other policies. Naic Cob Rules Health. COB is an industry standard that was created by the National Association of Insurance Commissioners (NAIC) in conjunction with the insurance industry. This model applies to all commercial group products. https://www.insure.com/health-insurance/how-coordination-of-benefits-works The Blue Cross and Blue Shield Service Benefit Plan, per our contract with the U.S. Office of Personnel Management (OPM), follows the National Association of Insurance Commissioners (NAIC) rules on which plan pays first when you are covered by two (or more) group health plans. The most common rules for determining the COB order of payment are the Non-Dependent/ Dependent Rule, the Active/Inactive Rule and the Birthday Rule. Coordination of Benefits (COB) is the process of determining which of two or more insurance policies will have the primary responsibility of processing/paying a claim and the extent to which the other policies will contribute. Adjustment codes list for coordination of benefits (COB) claims (PDF) Contact the practice management support team and/or the clearinghouse you use to submit your electronic claims. ��� ��������K�@2* �(���bpfIN�FHbRN�B~��s~^ P�X�� � T . (1) If an individual is covered by 2 or more plans, the rules for determining the order of benefit payments are as follows: (a) The insurer that issues the primary plan shall pay or provide benefits as if a secondary plan does not exist. • Contact your employer or union benefits administrator. Under the NAIC rules, the plan that pays first is known as the primary plan; the one that pays second is known as the secondaryplan. h�23�P0P03�T07W���w�/�+Q0���L)�6�0J)�Ic0i The model implements guidelines for how the COB process is conducted and claims are paid. The insurance industry developed a set of guidelines on COB during the 1960s that it voluntarily included in policies.5 In 1970, the National Association of Insurance Commissioners (NAIC) adopted its first model regulation on coordination of benefits. However, the commissioner’s authority is limited by the requirements of Health Insurance Portability and Accountability Act of 1996 (HIPAA) with respect <> Medicare NAIC Model Laws, Regulations, Guidelines, and other Resources This comprehensive publication provides quick access to every NAIC Model Law, Regulation, and Guideline. M e d i c a r e . Your Employer Plan will often have a specific section entitled “Order of Benefit Determination Rules” which sets forth how your Employer Plan identifies the Primary Plan. %PDF-1.7 2705 0 obj <>stream COB also applies when you or your dependents have health coverage under Medicare, worker’s compensation or motor vehicle or homeowner’s insurance. Under COB, the benefits of one plan are determined to be primary and are first applied to the cost of care. h�237W0P���w�/�+Q05���L)�623��)����T��$���� yvy �L' ˇ��7�r�ˈXftԧUٽ�[D���>i�E��&��ʲL�c��8WF��. Coordination of Benefits (COB) Definition. National Association of Insurance Commissioners’ (NAIC) rules are applied to determine the primacy of benefit coverage. Included with every model is a state action page that cites each state's enacted model or similar legislation. Participating health plans supply information to the COB Smart registry each week, where it is compared with data from other health plans to identify members with overlapping benefits. applied by HMK if HMK were primary . It is not a law. Further, state COB laws are pre-empted because they apply to self-insured plans. It clarifies what is meant by “flip-flopping of fields on an MSP occurrence” and explains how the COB Hierarchy rules work. It may include rules about who pays first. Drafting Note:Many plans negotiate rates with physicians, hospitals a nd other providers that are lower than the providers’ usual and customary charges using other reimbursement methodology, such as relative value schedule reimbursement or other similar reimbursement methodology. <> • Call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. TTY users can call 1-855-797-2627. COB can be complicated, especially if you and your spouse have different plan types, for instance, if … For Medicare Plans, we apply current guidelines from Medicare. 3 0 obj ERISA is silent with regard to COB, so self-funded health plans may create their own COB rules (another example of why moving to a self-insured program is advantageous!). (e) COB savings shall be reported by experience rated carriers each year along with the Carrier's annual accounting statement in a form specified by OPM. endstream endobj 2706 0 obj <>stream Blue Cross follows NAIC (National Association of Insurance Commissioner) and CMS (Centers for Medicare and Medicaid Services) guidelines. Sec. They may have their own guidelines or tips about submitting COB claims. The NAIC is the authoritative source for insurance industry information. To determine which plan is primary, SAMBA applies the guidelines from the National Association of Insurance Commissioners (NAIC). If negative, then no HMK payment made to provider; member liability . Drafting Note: States may wish to grant the commissioner rulemaking authority to further define that coverage which falls within the definition above. &�Ad�~@bQ*P����%H@?�� (��Zlg�n�%�(�Y��!�a@� ��*� Medica uses the following methods for calculating COB benefits: ... We follow the member's plan document to determine which COB method to … Coordination of benefits (COB) is employed when a member has healthcare coverage from more than one source. h��W_o�6�*z�0�eQ���M�b�m��t�Ê>�R�5��E�b�IK����-�@�����S:!�)K���J)�\��u�#S�,I���P���Q�e!������������w��nYo:�K-�y��}�<>u��}[���B��jU=�D���v��f�_w`˄�ڰ�{�^U�f���m��w��Sܴ�j�5ˮ�u������[-�m�-���v��V���FK�}�U���Nf���5�R���k��'�����{̐R&�#�~�Y���1��l.7�&~_5�]7��x��=?�]�c�5@�x��Q(�ۗ�c�����iwg��%)��( Highmark has adopted the National Association of Insurance Commissioners (NAIC) Model COB Regulation. Health Details: Details: health plans and the person intends to contribute to a health savings account established in accordance with Section 223 of the Internal Revenue Code of 1986, the primary highdeductible - health plan’s deductible is not an allowable expense, except for any health care expense incurred naic cob model naic cob model regulation <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 19 0 R 20 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> C. The order of benefit determination rules determine whether This Plan is a Primary Plan or Secondary Plan when the person has health care coverage under more than one Plan. HMSA certificates primarily base their coordination of benefits provisions on the order of benefit determination guidelines recommended by the National Association of Insurance Commissioners (NAIC). 3. h�2�P0P0�T05Q���w�/�+Q02�w�,*.�(��$ن���`^HeA��iINf^j��P����X %PDF-1.6 %���� COB Calculations. endobj The NAIC provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. endstream endobj 2707 0 obj <>stream of Insurance Commissioner’s (NAIC) Coordination of Benefits Model Regulation, but it is consistent with it, including modifications to the NAIC model adopted in 2013. x��ko�6�{��~��5#R�E ��v�uo�>t�Avd[W��Irr��73�dْ�8a{$�dJ��g��Y�̣Y�.//��"�-����MZ������m|�5Z$��H���o�i��>�igWW����������d��J���g���m��n���.> &w���� X�0��p7`*䮂oְ��|���lAWAy�����#6����r~�����aЯZԏ��17�cp#��aD͸P��:�!��.w�p!6C�|^G�8dw)���_n��������sN��Bz�${��EI2�bw%��u�l�u�[SZ��s�P[�i�:8ޒK��#��#�;��7�������{�����^����ViG8�ʻ������Ь�/a�G��n� 6֣�X��hU����'��;��E����l�fp�n�,��E���K������o}X�����4O�({H6�/b��Ϝ���e� ~�Gp�n݌'r�}\R����|��x],�U�w��z�z\���V��>�����SD �|. 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. How Do I Know Which Is the Primary Payer? Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan). (b) If the individual is covered by more than 1 secondary plan, the order of benefit determination rules Page 3 of 25 Slide 3 of 25 - Course Overview Slide notes This course was created to provide background information as to why the COB Hierarchy Rules were implemented. 1 0 obj Our expert solutions support the efforts of regulators, insurers and researchers by providing detailed and comprehensive insurance information. Use one of our vendors to submit COB claims Submit claims through Availity 0a9�8��*�ķ�������N&����}�t7��^�]v?��:Y�_���{�eP(��v�S(\Ж��~I��D� the national association of Insurance Commissioners (naIC) guidelines, as well as Medicaid, Medicare, and commercial business, helps us support all lines of business. The primary plan must pay benefits as if the secondary insurer did not exist, Huckaby says. stream COB Hierarchy Rules Monday, October 5, 2020 . endstream endobj 2708 0 obj <>stream %���� credit. 3. NAIC’s Model State Law: Dependent Coverage for Individuals to Age of 26 The National Association of Insurance Commissioners (NAIC) is composed of the state government officials charged with regulating insurance companies in each state or territory. Sensitivity: Knowing that member experience affects plan satisfaction, we make sure that all COB activities are done with as little member engagement as possible. The NAIC has been developing Model State Laws for over 100 years to encourage uniformity in the endobj This regulation is the most common methodology used for calculating a secondary payment in COB situations. “Most payers follow state law and NAIC COB requirements.” 3. 2 0 obj After considering what has been covered by the primary plan, the secondary plan Medica follows the National Association of Insurance Commissioners (NAIC) COB guidelines in determining primary and secondary payers. The NAIC guidelines do not apply to Medicare, COB is our process for ensuring that our members receive full benefits and helping to prevent over-payment for services when a member has coverage from two or more sources. This clause prevents duplicate payments on claims and follows guidelines established by the National Association of Health Insurance Commissioners (NAIC). A majority of the states have adopted versions of the model regulation, and rules that are consistent with the NAIC model will promote market efficiency, especially in the context NAIC Consistent COB Other Insurance (OI) payment is subtracted from the Highmark (HMK) payment $ 32 (HMK Payment) - 60 (OI Payment) $- 28 . In the past five decades, the NAIC has revised the model several times to reflect changes in the healthcare industry. The National Association of Insurance Commissioners (NAIC) is the state-based standard-setting organization governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. The COB rules, with which compliance has always been permissive rather than mandatory, have been in effect since 1988 in essentially the same form, and became applicable to health maintenance organizations (HMOs) when the Department of Health and Senior Services adopted rules regulating HMOs on February 18, 1997 at N.J.A.C. Magellan complies with federal and state regulations for COB and follows COB guidelines published by the National Association of Insurance Commissioners (NAIC). Also referred to as COB, coordination of benefits occurs when an individual is in possession of more than one insurance policy and when it comes to processing a claim, the policies are assessed to determine which will be assigned with the primary responsibility for covering the predominant share of the claim costs.The process also involves assessing the extent that other policies held will contribute … Federal Employees Health Benefits program carriers are obligated to follow standard coordination of benefit rules established by the National Association of Insurance Commissioners (NAIC) in … When determining which plan is primary, coordination of benefits (COB) provisions are based on guidelines recommended by the National Association of Insurance Commissioners (NAIC). State insurance … <>/Metadata 85 0 R/ViewerPreferences 86 0 R>>
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