Under what circumstances will health insurance be able to bounce a claim for an indivdual other then coding errors and COB with spouse?

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Asked August 26, 2013

1 Answer

One of the problems you may run into when you have more than one health insurance policy is a tendency for one insurer to try and pass the buck the buck to the other insurer. Coding errors are typical, and COB procedures are supposed to reduce claims refusal, but there are still areas where you, as a consumer, need to beware.

Coordination of Benefits, COB, is regulated by state laws, so the exact way it works will vary accordingly. The purpose of the regulation is to prevent claim payouts from exceeding 100% of the actual claim value by spitting claims between carriers. COB allows the insurance companies to negotiate responsibility and payments, but it also allows them to track claims for individual procedures. If one company has reason to believe that a claim was or will be paid by another company, they can bounce the claim out as a duplicate billing.

Many people believe that the medical care for their children could be tedious if they have more than one insurance plan, but the rules for insurance companies are plain, and the decision of which insurer is the primary carrier is made by determining which of the policyholders has the earliest birthday in the year. For example, if your birthday is in October and your spouse's birthday is in May, then the health insurance for your spouse will be the primary carrier for your family's primary needs. In that situation, your insurance would act as a backup to cover costs not covered by the primary plan.

Any time a claim is denied, you should be informed in writing of the reason for the coverage bouncing. If you believe the denial was in error, you have 30 days after receiving the denial to appeal the decision. Many times, the denial is provisional anyway, only requiring more information before the debt can be paid.

Answered August 26, 2013 by Anonymous

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