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Coordination Of Benefits (COB)

EmblemHealth Community-Rated Groups — 2 to 50 Employees

Coordination of Benefits (COB) procedures are designed to ensure that when a member is covered by more than one insurer, the costs of health care are appropriately assigned to the correct insurer. This section describes EmblemHealth's COB procedures.

COORDINATION OF BENEFITS (COB)

If the EmblemHealth plan is the primary plan, claims should be filed with EmblemHealth first. If the subscriber is covered by another insurer, this should be indicated on the claim form. If EmblemHealth is the secondary plan, claims should be filed as follows:

• For medical benefits: After filing the claim with the primary carrier and receiving an Explanation of Benefits (EOB) detailing that insurer's reimbursement, the subscriber should submit to EmblemHealth a medical claim with an itemized bill from the physician and a copy of the correlating EOB from the primary carrier.
• For hospital benefits: The subscriber should inform the hospital that EmblemHealth is the secondary plan if he or she is admitted to the hospital or receives emergency room services. For elective outpatient services, the subscriber should use the EmblemHealth hospital outpatient claim form and complete Part E on the reverse side of the form. The hospital will forward a copy of the bill to EmblemHealth for processing.

If the primary insurer rejects coverage for any services received, the subscriber should mail a copy of the rejection statement with his or her claim submission to one of the following addresses:

• For EmblemHealth EPO, EmblemHealth PPO, InBalance EPO, ConsumerDirect EPO and ConsumerDirect PPO
  PO Box 3000
  New York, NY 10116
• For EmblemHealth CompreHealth
  PO Box 2845
  New York, NY 10116

Other Health Insurance Questionnaire

In some cases, EmblemHealth may ask for information about additional coverage in the form of an Other Health Insurance Questionnaire. The questionnaire must be completed by the subscriber and returned to EmblemHealth for the claim to be considered for payment.

Please note that the Other Health Insurance Questionnaire is not to be used as an enrollment document. All other health insurance information is requested at the time of enrollment by completing Section III of the EmblemHealth Transaction Form.

Overview of the Other Health Insurance Questionnaire

Section A of the questionnaire requests basic information about the subscriber. The questionnaire also asks for basic information about the subscriber's spouse in Section B. If any family member has other health insurance coverage, including Medicare, the subscriber must complete sections C and D of this questionnaire. The subscriber must fill in the names and addresses of all other health insurance carriers. The effective date for all other health insurance plans must be indicated. The subscriber's signature and date are required in Section E of the questionnaire.

Forms should be submitted to one of the following addresses:

For EmblemHealth EPO, EmblemHealth PPO, InBalance EPO, ConsumerDirect EPO, or ConsumerDirect PPO, send the form to:

EmblemHealth – COB Unit
PO Box 2804
New York, NY 10116

For CompreHealth or CompreHealth EPO, send the form to:

EmblemHealth – COB Unit
PO Box 9091
Melville, New York 11747