![]() ![]() ![]() The coverage of the parent whose birthday falls first in the calendar year is the primary carrier for the dependent(s). Birthday rule: The “birthday rule” applies to dependent children covered by parents who are not separated or divorced.Dependent/non-dependent rule: The benefit plan covering the individual as an employee, member or subscriber or retiree is primary over the benefit plan covering the individual as a dependent.COB provision rule: The benefit plan without a COB provision is primary.When a member has more than 1 commercial health insurance policy, primary coverage is determined based upon model regulations established by the National Association of Insurance Commissioners (NAIC). We cannot crossover in reverse.ĭetermining the primary payer among commercial plans Note: If Medicare is the secondary payer, you must continue to submit the claim to Medicare. We may process these claims as secondary without a claim form or remittance advice from your office. This means Medicare will automatically pass the remittance advice to us electronically after the claim has been processed. We participate in Medicare Crossover for all our members who have Medicare as their primary benefit plan. When you receive the primary carrier’s explanation of benefits (EOB)/remittance advice, submit it to us along with the claim information. If Oxford is secondary to a commercial payer, bill the primary insurance company first. The secondary benefit plan pays the difference between the allowable expense and the amount paid by the primary plan, if the difference does not exceed the normal plan benefits which would have been payable had no other coverage existed. ![]() Under COB, the primary benefit plan pays its normal plan benefits without regard to the existence of any other coverage. Requirements for claim submission with COB If a claim is submitted past the filing deadline due to an unusual occurrence (e.g., health care provider illness, health care provider’s computer breakdown, fire, flood) and the health care provider has a historic pattern of timely submissions of claims, the health care provider may request reconsideration of the claim.
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