When you have other insurance in addition to Priority Health

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 Priority Health and also your spouse's health plan through his/her employer or by other coverage, such as workers' compensation or auto or homeowners insurance.
• Your spouse is covered by insurance through his/her employer and your Priority Health policy.
• Your children are covered by your health insurer and that of their other parent.
• Someone in your family is covered by Medicare and also has Priority Health coverage to pay for services not covered by Medicare.

Q: How does coordination of benefits work?

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.

Being covered by more than one insurance plan does not mean you will have no out-of-pocket expenses on a medical claim. Your out-of-pocket costs will vary based on the benefits provided by each plan.

Q: How do I report my other insurance coverage?

If you are covered by more than one insurance plan, it is important to:

• Tell your employer or Priority Health if you or any of your dependents are covered by more than one group health plan.
• Provide Priority Health with any paperwork that may help us decide which health plan is primary, including court orders or other papers.
• Respond promptly when we ask you for information about other insurance coverage. This helps make sure your claims are processed promptly.

Contact our customer service department to report your other coverage.

Q: Why does Priority Health need this information?

To ensure:

• 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

Q: How often does Priority Health need this information?

We update this information every 2 years. If we receive a claim for health care services for you or your dependent and we have not checked your coordination of benefits information in 2 years, we'll send you a letter asking you to update this information so we can pay the claim. You can either mail your information back or call Customer Service. Please note, some information, such as a divorce decree or court order, can't be accepted over the phone.

Q: How do I know which insurance plan is primary and which is secondary?

Here are some of the "rules" that help us decide which plan is your primary insurance plan:

1. A plan doesn't have a provision for coordination of benefits is the primary payer.
2. The plan that covers you as an employee, rather than a dependent, is the primary payer.
3. When a dependent child is covered by both parents' 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.
4. 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.

To learn more about coordination of benefits, see your coverage documents. Go to standard coverage documents for Priority Health plans.