Coordination of Benefits. Effective September 1, 2009 medical insurance plans will be subject to clearly defined time frame requirements for the processing of claims involving coordination of benefits. The goal of the amended regulation is to expedite the payment of both the primary and secondary claims. Amendments to WAC 284-51-215 require plans to cooperate when more than one plan covers an individual, and to determine which plan is primary within 30 days. The primary plan is then required to pay 95% of claims within 30 days of the determination it is the primary carrier, subject to extension if the plan must wait for needed information from the provider. The amendments also require the secondary plan to process claims within 30 days of receipt of the primary plan’s explanation of benefit information needed for the secondary plan to process the claim. If the secondary plan receives a claim without adequate information from the primary plan, it must notify the enrollee or primary plan as soon as possible, but no longer than 30 days. If a primary plan does not adjudicate a clean and complete claim within 60 days, the provider or enrollee may submit the claim to the secondary plan which must then pay the claim as the primary plan within 30 days. The new provisions do not apply when Medicare is the primary plan. These new provisions should provide both enrollees and providers with an important new tool to expedite the timely processing and payment of claims involving coordination of benefits. As new provider and facility agreements are negotiated with health plans in Washington, these amendments should be incorporated into the agreement language governing coordination and payment of benefits.
To see the revised rule click here.
