Helpful hints in determining primary payors:
The benefits of a healthcare plan that does not have a coordination of benefits provision or non-duplication provision shall in all cases be the primary payor;
If the member is covered under more than one plan, the plan that covers the member as a subscriber will be considered primary. The plan that covers the member as a dependent will be considered secondary; and
If the member is covered under two plans as the subscriber, then the group health plan that covered the member the longest would be considered primary.
When MHP and another group health insurance plan cover the same child as a dependent of married parents, the birthday rule is used to decide the order of benefits determination:
The benefits of the plan of the parent whose date of birth comes first in the year (month and day only) are determined first, followed by the benefits of the plan of the parent whose date of birth is later in the year; or
If both parents have the same date of birth, the benefits of the health plan of the parent that covered the child the longest are considered as primary.
When MHP and another group health insurance plan cover the same child as a dependent of both parents who are separated or divorced, benefits are determined in the following manner:
First, if the child is covered by a separation or divorce decree which outlines financial responsibility for the medical, dental and other healthcare expenses of the child, the benefits of that parent’s health plan will be determined as primary;
In the absence of a decree outlining financial responsibility, the health plan of the custodial parent is considered primary;
If there is joint custody and both parents carry the dependent on their plan, MHP follows the 'birthday rule.'
If both parents have the same date of birth, the benefits of the health plan of the parent that covered the child the longest are considered as primary;
Second, the benefit of the health plan of the parent with custody of the child;
Then, the benefit of the health plan of the spouse of the parent with custody;
Then, the benefits of the health plan of the parent without custody of the child; or
If there is joint custody and both parents carry the dependent on their plan, then MHP follows the 'birthday rule'.
MHP does not coordinate benefits or services provided to a member pursuant to any worker’s compensation laws, no-fault automobile insurance, any federal, state, or local government or community program providing medical benefits or reimbursements of medical costs, or any type of employer’s liability insurance.
At the time of enrollment, each MHP member is requested to complete the coordination of benefits information on the enrollment form. MHP will request that this information is updated from time-to-time. Should a request to the member be outstanding, claims may be held until the information is received.
Medicare’s COB rules depend on the size of the group, and the reason the member is eligible for Medicare coverage. If this information is unknown, please contact Provider Service Department 314-214-8137 or 800-596-4315 for assistance.
When a member is covered by both Medicare and MHP, the following rules apply:
Employers with less than 20 employees:
Active, Retired, or COBRA/State Continuation Members: If the member has Medicare coverage because he or she is over age 65, Medicare is primary; and
Active, Retired, or COBRA/State Continuation Members: If the member has Medicare due to a disability, Medicare is primary.
Employers with 20-100 employees:
Active Members: If the member has Medicare coverage because he or she is over age 65, MHP is primary;
Retired or COBRA/State Continuation Members: If the member has Medicare coverage because he or she is over age 65, Medicare is primary; and
Active, Retired, or COBRA/State Continuation Members: If the member has Medicare coverage due to a disability, Medicare is primary.
Employers with more than 100 employees:
Active Members: If the member has Medicare coverage because he or she is over age 65, MHP is primary;
Retired or COBRA/State Continuation Members: If the member has Medicare coverage because he or she is over age 65, Medicare is primary;
Active Members: If the member has Medicare coverage due to a disability, MHP is primary: and
Retired or COBRA/State Continuation Members: If the member has Medicare coverage due to a disability, Medicare is primary.
Note: All members not covered as 'Retirees' or on a 'COBRA/State Continuation' plan are considered 'Active.'
When a member who is not eligible for Medicare for any reason other than End Stage Renal Disease, MHP is the primary carrier for all treatment received by the member, including kidney transplant services, for the first 33 months after the initiation of dialysis treatment. This time period is calculated beginning the first of the month during which dialysis began.
After this time has elapsed, Medicare becomes the primary carrier. Medicare remains the primary carrier until the earlier of the following events occur:
Twelve months after the month the member no longer requires dialysis treatment or,
Thirty-six months after a kidney transplant.
If the member has resumed receiving dialysis services at the end of the 36 month period, Medicare will remain primary for as long as the member continues to receive treatment.
If the member has not resumed dialysis treatment, MHP becomes primary again.
(Note: If the member receives a second transplant before the 36 month recovery period has elapsed, a new 36 month recovery period is initiated.)
If the member must begin receiving dialysis treatment after MHP has reverted to the primary carrier, another coordination period will begin (MHP will again be the primary carrier for the first 30 months following the initiation of dialysis treatment).
When a member is eligible for Medicare for reasons other than End Stage Renal Disease and MHP was the primary carrier before the initiation of dialysis, the above-referenced guidelines apply. If MHP was the secondary carrier before the initiation of dialysis, MHP remains the secondary carrier throughout the duration of the member’s treatment for End Stage Renal Disease.
All group coverage plans are primary to Medicaid coverage. Such third party liability is defined as any individual, entity or program that is or may be liable to pay all or part of the healthcare expenses of the individual and can therefore be considered as a funding resource. State regulations require that providers take all reasonable measures to identify legally liable third parties and to submit evidence of other insurance coverage to the State of Missouri on an Insurance Resource Report.
Authorization Requirements When Mercy Health Plans is Secondary Payor
For purposes of this section, 'authorization requirements' refers to referrals, prior authorizations, and network limitations of the primary carrier.
When MHP is the secondary insurance for members, and members have met the authorization requirements of the primary insurance carrier (as verified by the information received on the primary carrier’s explanation of benefits), MHP’s authorization requirements are then waived. MHP will pay up to its allowable for the service.
If members did not meet the authorization requirements of their primary carrier, but have met MHP authorization requirements, MHP processes the claim in the normal manner, accounting for payment, if any, from the primary carrier.
If members did not comply with the authorization requirements, MHP reduces or denies the claim, as appropriate.
PAYMENT REFUND NOTIFICATION
This refund notification pertains to the following:
Patient Name: ________________________________________________________________
Patient ID number: ____________________________________________________________
Date of Service: ________________________________
Claim Number: _________________________________
Check Number: ________________________________
Amount: ______________________________________
Reason for refund (please check all that apply):
_______ Duplicate payment due to:
______ Other insurance paid as primary (attach primary carrier’s EOB)
______ Claim previously paid on ____________ (Date paid)
______ Other:__________________________________________
_______ Not our patient
_______ Service not performed
_______ Service billed in error
_______ Other:_______________________________________________________
PLEASE SEND THIS COMPLETED FORM WITH COPY
OF THE ORIGINAL REMITTANCE ADVICE TO:
Mercy Health Plans
ATTN: Adjustment Unit
PO Box 4568
Springfield, MO 65808-4568