Coordination of Benefits

What is Coordination of Benefits or COB?

Coordination of Benefits is the process insurance companies use to determine how to cover your medical expenses when you’re covered by more than one health insurance plan. It clarifies which insurance company pays what by determining which plan is the primary payer and which is the secondary payer. It also ensures proper claim processing and helps avoid overpayment or duplicate payments.

How do primary and secondary insurance policies work together?

It is possible to have more than one insurance policy at one time. In that case, your primary insurance policy would pay your claims first and then any remaining balance would be transferred to the secondary policy for processing.

As an example, someone might have Aetna as their primary insurance through their employer and United as their secondary insurance through their spouse. 

Disclaimer: If you are unsure which of your insurances is primary or secondary please contact your insurance to figure out which is primary, or if you have any additional questions.

What is coordination of benefits?

Coordination of benefits is the process of determining which of your policies will serve as the primary and secondary insurance.

Does Alma accept secondary insurance?

Alma does not currently accept secondary insurance. As a result, we ask that you only provide us with insurance information from your active, primary policy. If you submit details for a secondary insurance policy, your claims will be denied by the insurance company. You will be responsible for each session at out-of-pocket rates as determined by your provider unless you are able to provide us with primary insurance information that is accepted by Alma.

Please note, that your primary and secondary insurance policies are not interchangeable. The primary policy is determined by the insurance company and can not be altered to suit individual situations.

For example, if you have Aetna as your primary insurance and United Healthcare as your secondary, but the provider you want to see only takes United Healthcare and not Aetna, you can not use your United Healthcare as your primary.

Alma also cannot submit claims to your primary to be denied first and then submit to your secondary. The secondary insurance will not process claims without payment from the primary insurance first. These are policies enforced by the insurance companies, not Alma.  

How does an insurance company determine primary and secondary insurance?

As a general rule, insurance companies will follow the guidelines listed in the table below when determining primary and secondary insurance:

 

Situation Primary Secondary
You’re under 26 and covered by your school or employer’s plan and your parents’ health plan. School- or employer-sponsored coverage Parents’ coverage
You’re married and you and your partner have insurance coverage through your respective employers. Your employer’s coverage Your spouse’s employer coverage
You’re under 26 with married parents and both parents cover you under their separate policies. The parent whose birthday is first in a calendar year (also known as the birthday rule) The parent whose birthday comes second in a calendar year
You’re under 26 with divorced parents and both parents cover you under their separate policies. The parent with custody of the child. If parents have joint custody, the birthday rule applies The parent who doesn’t have custody, if applicable, or the parent whose birthday comes second in a calendar year
If you are retired or covered by Medicare/Medicaid Medicare will ALWAYS be the primary You or your spouse's previous employment insurance or any insurance plan you have opted to cover what Medicare does not.

 

What happens if my insurance company encounters an issue regarding my coordination of benefits?

If Alma receives a notice that there is an issue with your coordination of benefits (primary vs secondary insurance), our team will reach out and ask you to contact your insurance company directly. We’ve provided  step-by-step guidance below.  You should notify us of the outcome via email after you’ve clarified your coordination of benefits information with the insurance company. 

Information to have on hand for your call with your insurance:

  1. Date of Birth
  2. Member ID for primary insurance
  3. Date of Services / Appointment Dates: XX/XX-XX/XX
  4. Name and member ID of secondary insurance (if applicable)

 

Step-by-step Guidance for clarifying your coordination of benefits:

  1. Call the number on the back of your insurance card
  2. Follow the prompts on the automated system. They typically ask for your member ID and other personal information to verify your identity.
  3. Once through the prompts, the automated system will ask for the reason for your call. Simply say: Claims. This will get you to the claims department
  4. Once over to the claims department, the automated system will ask what category the claims fall under. Choose Mental Health or Behavioral Health
  5. Once a representative is on the line, tell them: “I’m calling to verify my Coordination of Benefits information for my claim/claims XX/XX. This policy is my primary insurance.”
  6. The representative will likely ask you additional questions. Answer them to the best of your ability.
  7. Once your Coordination of Benefits has been updated and the hold removed, ask the representative to confirm all outstanding claims will be reprocessed.
  8. Finally ask the representative for a call reference number.

One week after Alma sends you the initial email notification, we will follow up with your insurance company to confirm one of the following:

  • That the policy you provided to Alma is your primary insurance, and the insurance company incorrectly denied the claim(s)
  • That the policy you provided to Alma is indeed your secondary insurance, and the insurance company correctly denied the claim(s)

What happens if Alma confirms that the policy is my primary insurance?

Alma will submit all affected claims for reprocessing. No further action is required from you. 

What happens if Alma confirms that the policy is my secondary insurance?

Unfortunately, secondary insurance policies are not accepted through Alma’s insurance program at this time. If you are unable to provide us with your primary insurance information or if your primary insurance is not covered through Alma, here is what you can expect:

  1. You and your provider will need to determine a new payment plan for future sessions
  2. You will be marked as ineligible for Alma’s insurance program until your information is updated

How can coordination of benefits issues be prevented?

In order to avoid a coordination of benefits denial, you should confirm that the insurance information you submitted to Alma is from a primary, active policy. Should you fall into one of the situational categories listed in the table above, we recommend speaking with your insurance company directly. 

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