Under the terms of the Network Provider contract, the Coordination of Benefits (COB) rules are subject to change. Following is a brief description of the rules that apply to COB:
- With the exception of claims when the primary insurance carrier pays zero, HealthChoice pays the remaining balance on covered charges after the primary carrier payment up to the HealthChoice allowable fee, subject to plan policy and provisions.
- When the primary carrier pays zero and the benefit is covered under HealthChoice, HealthChoice will deny the claim and then review if the service is medically necessary. If proven medically necessary, HealthChoice will cover the service up to the HealthChoice allowable, unless the reason for the primary carrier paying zero is related to a non-allowable expense. In that situation, HealthChoice will pay zero for the claim.
- Regardless of the primary carrier’s payment, HealthChoice must deny claims for non-covered services and services that exceed plan limits. Plan provisions apply.
An unofficial copy of HealthChoice Administrative Rules, which include the COB rules, is available on this website.