The Rules for Coordination of Benefits

With ever-changing insurance plans, limitations and policies, it’s hard to stay up-to-date. Are you confident that you and your team are 100% clear on how coordination of benefits work for you and your patients?

Without full knowledge of how to operate scenarios with patients who have dual insurance coverage, your practice could be losing significant revenue. Here are a few key things from the ADA…

What Is Coordination of Benefits?

Coordination of benefits takes place when a patient is entitled to benefits from more than one dental plan. Insurance plans will coordinate the benefits to eliminate over-insurance or duplication of benefits.

Scenarios and Rules

Scenario 1:

Your patient is the subscriber on two dental plans. Which plan is the primary plan? The plan that has covered the patient the longest is the primary plan.

Scenario 2:

Your patient has an insurance plan through her employer and an additional plan through her husband’s employer. Which plan is the primary plan? The plan your patient is the subscriber on is the primary plan, with the other as secondary.

Scenario 3:

Your patient has a dental plan through her new employer and either a COBRA or retiree plan through her old employer. Which plan is the primary plan? The plan through her current employer is the primary plan, with a COBRA or retiree plan as secondary.

Scenario 4:

Your 7-year-old patient has coverage through both her parents’ dental insurance plans. Which plan is the primary plan? The birthday rule applies. Coverage comes through whichever parent has the earlier birthday in the calendar year.

Scenario 5:

Your 10-year-old patient has coverage through both parents’ dental insurance plans. However, the parents are divorced. Would you use the birthday rule to determine which of the parents’ plans would be the primary plan? No. In the case that the parents are divorced or separated, the court’s decree would take precedence over the typical birthday rule.

A few facts…

• When verifying benefits for patients with dual insurance, always ask how the plans handle coordination of benefits and if there is a non-duplication clause.
• Only group/employer plans have to coordinate.
• If a patient has dual insurance and one of the plans is not through a group/employer but is an individual plan, it does not coordinate. Warn patients who are thinking of buying an extra individual dental plan on top of their group/employer plan to get more coverage. They cannot coordinate, so the individual plan would be useless.
• When a patient has a group/employer plan and Medicaid or Medicare, the group/employer plan is always primary and Medicaid or Medicare is secondary.

Bottom Line

Be sure your team members posting payments for dual insurance are fully aware of how coordination of benefits works as it relates to copayments, proper write-offs and credits.

By: Leah Lochner