Birthday rule
When each parent has family health insurance coverage, each has primary coverage for themselves and secondary coverage for their spouse under their respective plans. The parent whose birth date occurs earliest in the calendar year provides primary coverage for their dependent children. The other parent’s coverage would be secondary.
Divorce situations
The birthday rule usually applies unless a court order specifies otherwise. We require a copy of the court order indicating who is to provide coverage for dependent children in divorce, custody and paternity determination cases.
Medicare
When Medicare is involved, we may be primary based on the employee’s work status. For example, working or not working. Please refer to the Medicare section for additional information.
Claims must be sent to the primary plan first even if the employee believes the primary plan will not pay the claim. After the primary plan processes the claim, the Explanation of Benefits (EOB) will be mailed to the member and will indicate how the claim was processed.
The EOB must accompany the original claim and be sent to the secondary payer for processing. In most cases, COB provisions are designed so that the total benefits available from two or more health plans reimburse up to 100 percent of medical expenses, if possible. If you have any questions about which coverage is primary, please call our Customer Care Center at 800-279-1301.
Note: In most cases the service provider submits the claims to both the primary and secondary health insurance companies on your employee’s behalf.
Employees should notify us through our Customer Care Center immediately when they file any claim related to an illness or injury caused by a third party or if a third party is liable. This includes – but is not limited to – claims for:
In all cases except worker’s compensation, we will process the related illness or injury claims according to covered benefits and then pursue the responsible party for a recovery of benefits paid.
For worker’s compensation cases, we will only consider payment of work-related illness or injury claims according to covered benefits when the worker’s compensation carrier has denied medical benefits. A copy of the worker’s compensation carrier’s denial must be submitted along with notification of whether or not the member is appealing the denial.
Note: an employee and/or dependent whose claims have been flagged as a possible subrogation issue will be mailed an Injury Report Form asking for more information about the incident. The employee and/or dependents must complete the questionnaire within 10 days of receipt or the claims related to the injury will be denied.
To complete the form, the member can:
Your employees have the right to appeal a decision by filing a formal internal grievance. After the internal grievance process is complete, your employee may also have the right to request an independent external review. If the matter is urgent in nature, your employee may be entitled to an expedited independent external review.
Any time a claim is processed that results in member responsibility for the service, an EOB is generated and mailed to the member. At the same time an Explanation of Payment (EOP) is mailed to the provider of services. (EOBs are not generated if the only member responsibility is an office copay.)
The definitions below will assist you in reading an EOB and understanding any amount(s) that are the member’s responsibility:
Contract period
Your benefits are determined based upon your policy’s contract period. See your Member Certificate for specific information.
Service date
The date the service was provided.
Claim number
The internal number used by Dean Health Plan to identify your claim.
Amount allowed
The amount Dean Health Plan accepts as the maximum allowable fee to be paid to a provider as defined in your Member Certificate. The difference between a provider’s charge and the amount allowed may be the member’s responsibility.
Deductible
The amount that you must pay each calendar year before Dean Health Plan will pay for covered services as specified in your Schedule of Benefits. The amount or percentage that is your responsibility each time covered services are provided, subject to the maximums specified in your Schedule of Benefits. Depending on your plan, the required deductible obligation may be listed for an individual, for the entire family, or broken out into separate medical and pharmacy deductible limits depending on your plan.
Patient responsibility
The cumulative amount of the following: Amount not covered, Copayment/Co-insurance, Deductible and the difference in a provider’s charge and amount allowed amount (on certain policies, please see your Schedule of Benefits about maximum allowable fee). Member responsibility limits are capped at the maximum out-of-pocket expense as indicated on your Schedule of Benefits. Once this limit is reached, your employee is not responsible for any additional out-of-pocket costs until the following contract period.
Adverse benefit determinations
In the event of an adverse benefit determination as defined by the US Department of Labor, the reverse side of the EOB contains appeal rights available to your employee.
Your EOB is the key to understanding your health insurance coverage as you incur costs.
The form tells you exactly how your benefits were applied. It covers the particulars related to the visit.
It also tells you how much has been credited toward your out-of-pocket maximum or deductible this contract period.
