Medical Billing Forum

Payments => Insurance Payments => Topic started by: wharta on October 04, 2010, 07:20:24 AM

Title: coordination of benefits
Post by: wharta on October 04, 2010, 07:20:24 AM
I have a pt who has an individual policy with anthem and another with united by their parents with them as the dependant. They say that united should be their primary, but should'nt it be anthem?

How do I know which shuld be billed first?
Title: Re: coordination of benefits
Post by: Michele on October 04, 2010, 07:58:53 AM
What is the individual policy with anthem?  Is it thru employment?  Is it a private policy?  Can't tell who is prime without more info, but the best thing to do is to call both plans and ask.

Michele
Title: Re: coordination of benefits
Post by: Anand on October 04, 2010, 09:17:33 AM
I have a pt who has an individual policy with anthem and another with united by their parents with them as the dependant. They say that united should be their primary, but should'nt it be anthem?

How do I know which shuld be billed first?

Ditto to Michele, i would better call both the payors and find out who is the primary
Title: Re: coordination of benefits
Post by: wharta on October 04, 2010, 02:58:40 PM
They have autism, so they have the individual lumenos plan since 9/1/10, they are 3yrs old, but the united is family through the mothers employment sice 10/7.
For the lumenos plans we get paid 100% even though we are not in network due to the Indiana Mandate, but United will only pay at the out of network rate.
Title: Re: coordination of benefits
Post by: Ultraserve on October 04, 2010, 04:22:02 PM
I would still suggest you call both insurance companies and find out which is primary regardless what insurance pays 100% or what not. Or ask the parents, they should be able to tell you, if not, you call insurance companies like Michelle and others have suggested.  :-\
Title: Re: coordination of benefits
Post by: medauthor on October 05, 2010, 09:03:30 AM
wharta, the lumenos plan is an HRA or an HSA, correct?  If this is true--then I believe you should be billing United primary and using the lumenos plan to pick up the co-insurance.
Title: Re: coordination of benefits
Post by: wharta on November 22, 2010, 02:26:24 PM
As it turns out the lumenos plan was primary and the united secondary, since the lumenos was an individual plan and the united was under the mothers work insurance.
Thanks for all your help
Title: Re: coordination of benefits
Post by: Pay_My_Claims on November 23, 2010, 11:09:31 PM
As it turns out the lumenos plan was primary and the united secondary, since the lumenos was an individual plan and the united was under the mothers work insurance.
Thanks for all your help

Thats wrong....an individual plan is NEVER primary to a group policy no matter who the policy holder is.
Title: Re: coordination of benefits
Post by: PMRNC on November 24, 2010, 08:27:09 AM
Quote
Thats wrong....an individual plan is NEVER primary to a group policy no matter who the policy holder is.

I was thinking same thing. The reason being is the individual plan is a full contributory plan (fully paid for by insured) why would they be primary over an employer sponsored plan?
Title: Re: coordination of benefits
Post by: wharta on December 06, 2010, 11:50:58 AM
the individual plan is primary.
Title: Re: coordination of benefits
Post by: PMRNC on December 06, 2010, 09:24:58 PM
Quote
the individual plan is primary.

Based on What COB determination?  USUALLY individual plan's are NOT primary to employer sponsored or any other contributory based plan.
Title: Re: coordination of benefits
Post by: wharta on December 07, 2010, 12:03:03 PM
It is a health savings account and it is through the fathers job
Title: Re: coordination of benefits
Post by: PMRNC on December 08, 2010, 03:18:46 PM
An HSA will NEVER be a primary paying plan...  :o  HSA's are setup to pay out of pocket (copay, coinsurance, deductibles and non-covered services)
Title: Re: coordination of benefits
Post by: wharta on January 19, 2011, 02:42:41 PM
Well, I don't know what to say. The policy is primary and pays 100% of all charges due to the Indiana mandate for ABA therapy.
Title: Re: coordination of benefits
Post by: tlewis on January 24, 2011, 05:21:32 PM
Does the lumenos plan know they have United as well??? Don't know how many times I have had the pt be double covered with both plans stating they are primary.. unfortunatly for me this flags both plans for the patient to fill out a coordination of benifits which delays payment. Legally I would make sure Lumenos knows about United I know 100% payment is wonderful, however the added cost of having to fix it all later is not worth it.
Title: Re: coordination of benefits
Post by: tlewis on January 24, 2011, 05:25:29 PM
also Lumenos has a far longer period of time to ask for the money back then you do to file a timely claim. So if the patient stated at time of service that United was prime and you bill Lumenos then oh lets say 3 years down the road they want their money back you will be out 100% as it will be to late to bill United.
Title: Re: coordination of benefits
Post by: PMRNC on January 26, 2011, 08:04:33 PM
Does the lumenos plan know they have United as well??? Don't know how many times I have had the pt be double covered with both plans stating they are primary.. unfortunately for me this flags both plans for the patient to fill out a coordination of benifits which delays payment. Legally I would make sure Lumenos knows about United I know 100% payment is wonderful, however the added cost of having to fix it all later is not worth it.

I agree...this has to be the case..THERE is just NO legal explanation for an HSA to pay primary!!!!