When patients are eligible for benefits under two or more health insurance plans, the insurers will “coordinate” benefits to determine the order of benefits to establish proper claims processing.
When is coordination needed?
- When an individual is covered by their employer’s policy and is also covered under their spouse’s plan.
- When an individual has private or marketplace plan, but has an additional plan through a spouse or parent.
- When a child is covered by more than one parent, stepparent, or guardian.
- When a patient has Medicare or Medicaid in addition to being covered by commercial insurance plan.
How are benefits coordinated?
- If an individual is covered by their employer’s policy, this policy will pay before a policy where the individual is considered a dependent.
- If a child or dependent is covered by more than one person, several factors are considered:
- If the child/dependent is covered by multiple parents/guardians, the plan of the parent/guardian with the earlier birth date in the calendar year pays first. In some instances, a custody or court order might supersede the date of birth rule.
- If the child/dependent has coverage through an employer or post-secondary institution, these plans will always pay before a plan where the child is the dependent.
- Policy holders need to complete the coordination of benefits form with each insurance company and are obligated to disclose all policies. Claims may be held if coordination of benefits forms are not completed by policy holders. Policy holders must also communicate changes in coverage to their insurance company as well.
- Many children with autism or other disabilities are covered by Medicaid and/or additional funding sources. Typically, Medicaid is considered the payer of last resort. The patient’s parent/guardian is still obligated to disclose coverage to all insurers, and they will coordinate benefits.
Why is coordination needed?
- Coordination prevents both insurance companies paying for the same claim.
- It helps reduce the cost of insurance premiums.
- It helps the provider understand which policy to bill as primary, secondary, tertiary.
Coordination is just one piece of the puzzle of revenue cycle management. Missing Piece Billing and Consulting are leading experts on ABA and behavioral health billing and revenue cycle management.
If you seek a partner that helps put the pieces together for you and your patients, contact Missing Piece today for your free evaluation at 765-628-7400 or firstname.lastname@example.org.