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Coordination of Benefits

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Option 1
Where the Health Plan is primary under applicable coordination of benefit rules, the Health Plan shall pay the reimbursement rates due under this Agreement as set forth in Exhibit [XXX].  Where the Health Plan is other than primary  under coordination of benefit rules referred to above, the Health Plan shall pay those amounts which, when added to amounts owed to Hospital from other sources, pursuant to the applicable coordination of benefits rules, shall not  exceed one hundred percent (100%) of the Hospital’s billed charges.

Option 2
Where the Plan is primary under applicable coordination of benefits rules, the Plan shall pay the reimbursement rates due under this Agreement as set forth in Exhibit  [XXX].  If Plan is the secondary Payer, then Plan shall pay Provider for services not paid by the Primary Payer at a rate representing the difference between Provider’s billed charges and the amount paid by the primary Payer; provided, however, that in no event shall Plan be obligated to pay more than 100 percent of the rates set forth in this Agreement and in no event shall Provider be entitled to total compensation exceeding 100 percent of its billed charges.

Option 3
a) Hospital agrees to cooperate with Payer in the Coordination of Benefits and other third-party claims for Covered Health Services rendered to Members.
b) In a case in which Payer, under the applicable Benefit Contract, is primary under applicable Coordination of Benefits rules, the reimbursement amount referred to in attached Fee Schedule shall be paid.
c) In a case in which Payer, under the applicable Benefit contract, is other than primary under the Coordination of Benefit rules, only those amounts shall be paid which, when added to the amounts received by Hospital from other sources, pursuant to the applicable Coordination of Benefits rules, equal one hundred percent (100%) of the Hospital’s billed charges. (Or, of the reimbursement amount specified in the attached Fee Schedule.)
d) Hospital may seek payment for the provision of Covered Health Services from other sources as available pursuant to the Coordination of Benefit provisions of the applicable Benefit Contract.  In such cases, Hospital may seek payment on a basis other than the rate referred to in the attached Fee Schedule.

Also see: State-by State Coordination of Benefits