COORDINATION OF BENEFITS AND SUBROGATION

Subrogation

Subrogation is a contract provision that allows healthcare insurers to recover all or a portion of claims payments if the member is entitled to recover such amounts from a third party. The third party’s liability insurance carrier normally makes these payments. A third party is another carrier, person or company that is legally liable for payment from the treatment of the claimant’s illness or injury. All claims you submit to Blue Cross must indicate if work-related injuries or illnesses are involved and if the services are related to an accident.

Providers should:

• Not require the Blue Cross member or the member’s attorney to guarantee payment of the entire billed charge.

• Not require the Blue Cross member to pay the entire billed charge up front.

• Not bill the Blue Cross member for amounts above the reimbursement amount/allowable charge.

• Charge the member no more than is ordinarily charged other patients for the same or similar service.

• Bill the member only for any applicable deductible, coinsurance, co-pay and/or noncovered service.

If amounts in excess of the reimbursement amount/allowable charge were collected, you should refund that amount to the member.


In the case of OGB claims, Blue Cross pursues recovery of claims payments and Blue Cross makes payments as applicable.

As  a  participating  provider  with  CarePlus  we  require  that  you  notify  the  Plan  of  any  third  party information  you  may  have  received  and  that  you  assist  the  Plan  in  complying  with  the  Medicare Secondary Payer rules.  In addition, if you are notified of a Medicare Set-Aside Plan please notify the Plan immediately.  You can contact the Plans COB / Subrogation department at 1-877-843-3870.  Please refer to the COB questionnaire located in the “Forms” section of this manual to assist you in submitting information to the Plan.  

CarePlus  is  subject  to  the  rules  and  regulations  as  defined  by  the  Social  Security  Act  and  the  CMS Medicare Secondary Payment (MSP) provision. Medicare Advantage Organizations are allowed four (4) provisions in which Medicare is considered a secondary payer. 

1.  Employer Group Health Plans (EGHP) and Large Group Health Plans (LGHP)
2.  Liability Insurance Plans
3.  No-fault Insurance Plans
4.  Workers’ Compensation Plans (WC)

Employer Group Health Plans (EGHP)

Policy:  Coverage under a health plan offered by an employer in which a Medicare beneficiary is covered as:

1.  An employee (age 65+) or
2.  As a dependent under another subscriber (of any change) covered under such plan

NOTE:  Medicare is the secondary payer for beneficiaries assigned to Medicare under the ESRD benefit for up to 30 months beginning when the individual becomes eligible for Medicare if the beneficiary was not otherwise eligible due to age or disability

Liability Insurance and No-Fault Insurance

Policy:  Types of liability include, but are not limited to automobile liability, malpractice, homeowner’s liability, product liability, and general casualty insurance.  Medicare is considered the secondary payer to all liability and no-fault insurance providers.

Workers’ Compensation (WC)

Policy:  Medicare  does  not  coordinate  benefits  with  Workers  Compensation  payers.  Workers’ Compensation assumes full liability for the payment of items and services related to a claim meeting their coverage requirements.

When  a  Member  has  coverage,  other  than  with  CarePlus,  which  requires  or  permits  coordination  of benefits from a third party payor in addition to CarePlus, CarePlus will coordinate its benefits with such other payor(s).  In  all cases, CarePlus  will coordinate benefits  payments  in  accordance  with  applicable laws and regulations and in accordance with the terms of its health benefits contracts. When permitted to do so by such laws and regulations and by its health benefits contracts, CarePlus will pay the lesser of: (i) the amount due under the prevailing agreement; (ii) the amount due under the prevailing agreement less the amount payable or to be paid  by the other payor(s); or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In no event, however, will CarePlus, when its plan is a secondary payor, pay an amount, which, when combined with payments from the other payor(s), exceeds the  rates  set  out  in  the  prevailing  agreement;  provided,  however,  if  Medicare  is  the  primary  payer, CarePlus  will,  to  the  extent  required  by  applicable  law,  regulation  or  Center  for  Medicare/Medicaid Services (CMS) Office of Inspector General (OIG) guidance, pay Provider an amount up to the amount CarePlus would have paid, if it had been primary, toward any applicable unpaid Medicare deductible or coinsurance. 

Recovery: Provider and CarePlus agree to use reasonable efforts to determine the availability of other benefits,  including  other  party  liability,  and  to  obtain  any  information  or  documentation  required  by CarePlus  and  Provider  to  facilitate  coordination  of  such  other  benefits.  Upon  request  by  CarePlus, Provider will provide CarePlus with a copy of any standard Provider forms used to obtain the necessary coordination of benefits information.

Payment Adjustment: Provider and CarePlus agree that retroactive adjustment to the payment including but not limited to claims payment errors, data entry and incorrectly submitted claims shall be submitted to Recovery of Over/Under Payment process.

Employment-related Injuries or Illness

There are generally three types of legal remedies available to members who sustain employment-related injuries or illnesses:

• Workers’ Compensation under state law – Workers’ Compensation under state law is a legal remedy whereby an employee who is injured within the course and scope of employment is usually entitled to certain benefits regardless of whether anyone was at fault.

• Longshore & Harbor Workers’ Compensation Act (LHWCA) - The LHWCA is a federal law that provides for the payment of medical care to employees who suffer “on the job” injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building certain vessels, regardless of whether anyone was at fault.

• Jones Act – The Jones Act is a federal law that provides protection only to “seamen” who are injured while working on a vessel.

Please understand that we do not make any coverage determinations as to which legal remedy would apply to a member’s injury.

We understand that it can be very difficult to determine which one of these legal remedies may cover a particular injury or illness; however, your patients may have medical benefits available to them under their Blue Cross contract. All claims for covered services, including those claims for which a third party may be liable, must be filed directly to Blue Cross. Please understand that services for injuries and illnesses that arise under the Jones Act, like any other covered services that do not fall under any workers’ compensation guideline, are not considered contractual exclusions, and therefore, must be filed with Blue Cross. Although services that fall under a workers’ compensation guideline are, in most circumstances, typically excluded under the terms of the member contracts/certificate of coverage, we strongly encourage our providers to file claims for these services with us. If the service is determined not to be covered by workers’ compensation or the particular contract does not exclude these types of services, you risk any future consideration by failing to meet administrative filing requirements. The current administrative claims process may deny an initial claim for employment related injuries however, please contact Customer Service so that we can work with your office to apply the appropriate member benefits.

Coordination of benefits does not apply in any of these scenarios.

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