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Other Party Liability

 

Coordination of Benefits

Coordination of Benefits (COB) is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim. COB is intended to prevent the duplication of benefits when a member is covered by more than one insurance carrier, including but not limited to: group health insurance, retiree benefits, auto insurance, and workers compensation.

Beneficiaries must be eligible for Original Medicare parts A and B to elect coverage with a SelectHealth Advantage plan. SelectHealth Advantage plans administer the benefits, process and pay claims, but they are separate from Original Medicare. Beneficiaries are eligible under three status types: Working Aged, Disability and End-Stage Renal Disease (ESRD).

The following are guidelines related to how SelectHealth Advantage® plans coordinate benefits with group health insurance policies.  Please note that SelectHealth Advantage will be the primary insurance carrier over individual and inactive group plans.

SelectHealth Advantage Working Aged

Active employer group insurance plans are primary to SelectHealth Advantage if the group has 20 or more employees.

Active employer group insurance plans are secondary to SelectHealth Advantage if the group has less than 20 employees.

SelectHealth Advantage Disability

Active employer group insurance plans are primary to a SelectHealth Advantage if the group has 100 or more employees.

Active employer group insurance plans are secondary to SelectHealth Advantage if the group has 99 or fewer employees. 

SelectHealth Advantage End-Stage Renal Disease (ESRD)

During the first 30 months of eligibility (referred to as the “coordination period”) any group health plans are primary to SelectHealth Advantage.  After the coordination period SelectHealth Advantage will become the primary insurance policy.

Auto, Workers’ Compensation and other liability insurance​ 

SelectHealth Advantage does not pay for items or services to the extent that payment has been, or may reasonably be expected to be, made through a no-fault or liability insurer or through Workers' Compensation (WC). SelectHealth Advantage may make a conditional payment when there is evidence that the primary plan does not pay promptly conditioned upon reimbursement when the primary plan does pay. Subrogation is responsible for recovering conditional payments when there is a settlement, judgment, award, or other payment made. When subrogation has information concerning a potential recovery situation, it will identify the affected claims and begin recovery activities. Beneficiaries and their attorney(s) should recognize the obligation to reimburse SelectHealth Advantage during any settlement negotiations.

Hospice ​

Hospice services related to terminal conditions are paid for by Original Medicare Part A and Part B, not SelectHealth Advantage.

Medicare Approved Clinical Trials

Original Medicare is responsible for the primary payment of approved clinical trials. SelectHealth Advantage will process these claims as secondary. Medical records may be requested.

Subrogation

The Subrogation team is involved in situations when a member is injured in an accident or event where a third party may be at fault.

All claims involving a personal injury case will be processed by SelectHealth, following all applicable COB rules, then sent to the state Office of Recovery Services (ORS) for subrogation to recoup any third party liability.​​

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