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COB part 1

100

This includes parents who live together, but are not married.

• The plan of parent/legal guardian whose birth date is earlier in the calendar year will be primary for children, and plan of parent/legal guardian whose birth date is later in the calendar year will be secondary.

Rule #2- The birthday Rule

200

• A plan that covers a person as an employee - who is neither laid off nor retired - is primary. The other plan may not have a rule for laid off or retired employees similar to this rule. In this case, Rule 4 is ignored.

Rule #4-

Active/Inactive Employee (Laid Off/Retiree)

300

In the case of a divorce or separation, a court decree may give one parent financial responsibility for the medical, dental, or other health expense of the dependent child. When this happens the cort order is primary.

Rule 3- Dependent child separated or divorce 

400

• There are situations when individuals can be covered under a group health plan and under a COBRA plan. If an individual was covered with a group health plan with their employer and had coverage under another group health plan through their spouse, they would have two group health coverages. If that individual then moved to a COBRA plan through their employer, they can still retain the group health coverage through their spouse. They would then have a COBRA plan and group health coverage.

Rule 5 - COBRA Continuation of Coverage

500

helps us determine the order of benefits if a member has more than 1 plan. 

The 7 rules of COB

COB part 2

100

• The plan that covers the person as an employee, enrollee, subscriber, or retiree (other than as a dependent) will be primary to a plan that covers same person as a dependent.
• This rule applies when:
  • Both spouses cover each other as dependents under their respective plans

Rule #1 Non-dependent/Dependent rule 

200

• The Advocacy where you can locate the 7 rules of COB

Eligibility advocacy 

300

• If preceding rules do not determine the order of benefits, the benefits of the plan that covered an employee longer are determined to be primary over those that covered the employee for a shorter period of time.

Rule 6 - Longer/Shorter Length of Coverage

400

If none of the rules from above apply, both plans should share expenses equally. One insurance company would call the other and inquire what its allowable would be. The plan with the higher allowable would then be used by each company, and each company would pay 50% of the higher allowable expense. This would allow the higher benefit to the enrollee.

Rule 7 - Shared Expenses

500

The 2 systems we can use to updated COB

ISET and CDB

ISET

100

Where you can locate the member's Care Path Opportunities or Referral offers.

The Advocate Dashboard

200

The tab and sub tab where you can locate notifications or prior authorizations. 

claims- notifications 

300

ASO/FI

Funding Arrangement

400

The 2 places we can look-up benefits 

AVA and IBAGG

500

Where you can find a list of in-network breast pump providers 

gold star- national ancillary list 

Miscellaneous

100

Where you can find the different plan's Open Enrollment information

Open Door

200

• Age (65 years or older)
• Disability
• End-stage renal disease (ESRD)

Medicare Eligibility criteria 

300

Where you can locate the Preventive Care Coverage Determination Guidelines.

Benefits and Coverage advocacy- preventive care section.

400

Where you can find the advocacies 

Knowledge Central 

500

allows network processing for out-of-network facility claims under certain circumstances.

RAPL, RAPS, and RAPLE