Coordination of benefits is the practice of two or more plans coordinating their provision of health benefits to members who have multiple coverage. Currently, PacifiCare Behavioral Health benefits are subject to the COB provision. You will find sample documents addressing COB issues in this manual.
Although many of the specifics regarding COB are not relevant to the provider, there are some that pertain to Pre-Authorization and primary coverage determination.
Pre-Authorization
PBH adheres to National Association of Insurance Commissioner (NAIC) guidelines with regard to coordination of benefits. We accept the medical necessity decisions made by the primary carrier if we have an obligation to pay for care as the secondary insurer. If we are the secondary carrier, we require the primary carrier's EOB. If as the secondary carrier we become primary (as when the member exceeds the benefit of the first carrier), then pre-authorization is required.
Primary versus Secondary Determination
Dependent Child (Parents Not Separated or Divorced)
PBH applies the "birthday rule" when determining primary coverage. (i.e., for dependent children, the plan of the parent whose month and day of birth occurs earlier in the calendar year is primary)
If one plan does not follow the birthday rule, then the rules of the plan which does not have the birthday rule provision shall be primary
Dependent Child (Parents Separated or Divorced)
If the parent with custody has not remarried, the plan of the parent with custody is primary over the plan of the parent without custody
If parents are divorced and the parent with custody remarries, the plan of the parent with custody is primary over the plan of the stepparent; the non-custodial parent's plan would be tertiary
If a court decree establishes financial responsibility for health care expenses, then the plan of the parent with such responsibility shall be primary
See sample form on next page: COB Dependent Inquiry
