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Coordination of Benefits Billing Guidelines

Coordination of Benefits (COB) is the process that determines the order in which health benefits are paid. COB also commonly includes other third party liability such as auto or homeowner’s liability. COB guidelines are established by the National Association of Insurance Commissioners (NAIC), Medicare, Medicaid and Michigan law. In all instances, HealthPlus will pay only up to the HealthPlus fee schedule, when combined with all other payment sources.

COB comes into play only when a claimant is covered under more than one group health plan, or has supplemental insurance such as homeowner’s, business owner’s, no-fault or workman’s compensation. The process begins in the HealthPlus Liability and Recovery system when the COB staff “flags” any claim that may be a potential COB case. If necessary, the COB Department gathers supporting documentation and coordinate HealthPlus coverage with any other health or liability coverage the claimant may have.

HealthPlus COB representatives interact with doctors, nurses and office staff personnel, auto and homeowner’s insurance companies and HealthPlus members, to investigate and identify COB opportunities.

Providers are requested to assist HealthPlus in obtaining other coverage information and to bill services to the responsible primary insurer. For claims which may be related to an accident, injury or other coverage, please indicate the primary insurance carrier on the claims form.

Submit Claims to:

HealthPlus of Michigan
COB Department
PO Box 1700
Flint, MI 48501-1700

If a HealthPlus member has primary insurance coverage through another carrier, or has another carrier with a deductible or copay required, the provider must submit the claim to the other carrier before billing HealthPlus. The exception to this is when the other carrier is traditional Blue Cross. In these cases, you do not need to send an EOP from Blue Cross to HealthPlus for office visits and/or injections. You may bill HealthPlus first, even when the traditional Blue Cross policy is primary.

When HealthPlus is the secondary insurer, submit a copy of the Explanation of Payment (EOP) from the other carrier, showing payment or denial of payment, with a claim. The filing limit is determined by the date on the other insurer’s EOP voucher, not the date of service.

Medicaid COB Exceptions

If a HealthPlus Partners member has additional insurance, HealthPlus Partners is always the secondary insurance. HealthPlus Partners will reimburse co-insurance and/or deductibles up to an amount that, when combined with the other primary carrier payment, will not exceed the Medicaid maximum fee.

HealthPlus pays particular attention to the occurrence, value and condition codes that are required, when applicable. Follow these links for a list of commonly used codes from the UB-04 Manual and required by HealthPlus when submitting a coordinated claim, with the corresponding Form Locators..

Occurrence Codes – Form Locators 32-35a-b

Value Codes and Amounts – Form Locators 39-41 a-b        

Condition Codes – Form Locators 24-30

If you have a specific question about the HealthPlus Coordination of Benefits policy, please call 1-800-345-9956, ext. 8193.

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