Coordination of benefits with other insurance

When you or a family member are covered by more than one health plan, Priority Health uses a system called coordination of benefits to determine how to coordinate with your other plan to pay for your medical services.

Examples:

  • You are covered by both Priority Health and your spouse's health plan
  • Your children are covered by your health insurer and that of their other parent
  • You are covered by Medicare and have Priority Health coverage to pay for services not covered by Medicare

Primary and secondary payers: How companies coordinate benefits

Under coordination of benefits, one health care plan is named the primary payer and the other is named the secondary payer. The primary payer pays your medical claims first; the secondary payer pays second.

  • We work with your other plan to make sure you receive the benefits covered by your plan, whether your Priority Health plan is primary or secondary.
  • We also coordinate benefits for claims covered by auto insurance plans.
  • If the amount we pay is more than we should have paid, we have the "right of recovery," to recover extra payments from the other companies or your health care providers. You must cooperate with us in these recoveries.
  • If you are paid for any services both by us and by another company, we have a right to be reimbursed by you for that overpayment.

Being covered by more than one insurance plan does not mean you will have $0 out-of-pocket expenses on a medical claim. Your out-of-pocket costs will vary based on the benefits provided by each plan.

Report any other health benefits/plans you have

We need to know if you have other insurance to make sure:

  • We are processing claims in the correct order
  • The combined payments from all plans do not add up to more than the covered health care expenses
  • There is no double payment of claims
Tell your employer or Priority Health if you or any of your dependents are covered by more than one group health plan, and send us any paperwork that may help us decide which health plan is primary, including court orders or other papers.

    Call Customer Service at the number on your member ID card to report your other coverage.

    Please note, some information, such as a divorce decree or court order, can't be accepted over the phone.

    How your health plan covers your kids 

    When a dependent child is covered by both parents' health plans, the plan of the parent whose birthday falls first during the calendar year (month and day only) pays first. This is known as the birthday rule.

    When a dependent child of divorced, separated or never-married parents is covered by both parents' plans, the primary payer is determined by:

    • Court order
    • Plan of the custodial parent
    • Plan of the spouse of the custodial parent
    • Plan of the non-custodial parent
    • Plan of the spouse of the non-custodial parent
    • The birthday rule
    • The plan that covers you as an active employee, instead of a retiree, is the primary payer.
    • The plan that is not a COBRA or continuation plan (when you have left your job but you still have health coverage) is the primary payer.
    • When none of the above rules apply, the plan that has covered you for the longest time is the primary payer.

    Learn more in your plan's coverage documents

    Search for "coordination of benefits" in your coverage documents.