Order of Benefit Determination
- Participating Physician Groups (PPG)
(does not apply to HSP)
Apply these rules in the order in which they are listed in determining which plan is primary and which is secondary:
- Rule One - Insurer without coordination of benefits (COB) provision - If one contract contains a COB provision and the other does not, the insurer without the provision is the primary carrier.
The following rules apply when there are two insurers and both contracts contain a COB provision:
- Rule Two - Insurer covering member as policy holder or subscriber - When the member is the policy holder or subscriber with one insurer and the dependent with another, the insurer that covers the member as the policy holder or subscriber is the primary carrier.
- Rule Three - Member is a dependent child with both insurers (birthday rule) - The insurer of the subscriber whose birthday is earlier in a calendar year is the primary carrier for dependents covered under that subscriber's group health plan. The insurer of the subscriber whose birthday is later in the calendar year is the secondary carrier for dependents covered under that subscriber's group health plan. This birthday rule applies to dependent children whose parents are living together but have never married. It does not apply to dependent children whose parents have been divorced or legally separated. Refer to the Order of Benefits for Dependent Children (PDF) chart for assistance in COB situations.
- Rule Four - Divorced or legally separated parents of dependent child with court decree - If the parents of a dependent child are legally separated or divorced and a court decree directs one parent to be financially responsible for the child's medical, dental or other health care expenses, the insurer of the parent who is financially responsible is the primary carrier.
- Rule Five - Divorced parents of dependent child with legal custody - When parents of a dependent child are divorced and the court has not assigned financial responsibility for the child's medical, dental or other health care expenses, and the parent with legal custody of the child has not remarried, the insurer of the parent with legal custody of the child is the primary carrier for the child, and the insurer of the parent who does not have legal custody is the secondary carrier.
- Rule Six - Stepparents - In the case of a divorced parent, when the court has not assigned financial responsibility for the child's medical, dental or other health care expenses, the insurer who covers the child as the dependent of the parent with legal custody of the child is the primary carrier, and the spouse of the parent (stepparent) with legal custody's insurer is the secondary carrier. The insurer of the parent without custody is tertiary.
- Rule Seven - When the court orders joint custody - When the court has awarded joint custody of dependent children to divorced or legally separated parents, the plan applies the birthday rule (rule three).
- Rule Eight - Retired and laid-off employees - When a retired or laid-off employee has more than one coverage, the insurer who provides coverage to the patient as an active employee is primary; the insurer providing coverage as a retirement benefit is secondary.
When rules one through eight do not establish an order of benefit determination, the insurer who has covered the member the longest is the primary carrier.
Right to Receive and Release Information
The plan and other health plans may share information for the purpose of applying these rules and determining benefits payable under multiple health plans covering the person claiming benefits. The plan need not tell, or obtain the consent of, any person prior to doing this. Each person claiming benefits from the plan must give the plan any facts it needs to apply these rules and determine benefits payable.