Under the terms of the network provider contract, the coordination of benefits rules are subject to change. HealthChoice will use the standard allowable calculation methodology for coordination of benefits. Following is a brief description of the rules that apply:
- Allowable expense is a health care expense, including deductibles, coinsurance and copayments, covered at least in part by any plan covering the person. An expense not covered by any plan covering the person is not an allowable expense. Any expense that a provider is prohibited (by law or by contract) from charging a covered person is not an allowable expense.
- The benefits paid by medical and dental plans will equal no more than the allowable expense.
- The amount of any benefit reduction by the primary plan because a covered person has failed to comply with the plan provisions is not an allowable expense. Examples of these types of plan provisions include second surgical opinions, precertification of admissions and failing to use the primary plan’s preferred provider arrangements.
- HealthChoice shall credit to its plan deductible any amounts it would have credited to its deductible in the absence of other health care coverage.
- There is no “lesser of” calculation involving the primary carrier and HealthChoice allowable amounts or of what HealthChoice would pay in the absence of other health care coverage. If the primary carrier paid zero on the entire claim, then HealthChoice will pay its normal benefits (unless bullet 3 applies).
- The only amount updated in the out-of-pocket max bucket is the true OOP the member has to pay, excluding charges for non-covered services, balance billing charges from non-network providers and amounts paid by third parties.
- HealthChoice requires verification of other insurance on a rolling 12-month basis.