You and your family members may have coverage under more than one health plan. Coordination of benefits (COB) is the procedure used to determine the amount of a claim that each plan should pay and to eliminate duplication of payment for services.
- Under COB, the plan that pays first is the primary plan.
- The secondary plan pays after the primary plan.
When you or your family members are covered by another group plan in addition to this one, Delta Dental will follow Ohio coordination of benefit rules to determine which plan is primary and which is secondary. You must submit all bills first to the primary plan. The primary plan must pay its full benefits as if you had no other coverage. If the primary plan denies the claim or does not pay the full bill, you may then submit the balance to the secondary plan.
Delta Dental pays for health care only when you follow the rules and procedures. If the rules conflict with those of another plan, it may be impossible to receive benefits from both plans, and you will be forced to choose which plan to use.
Plans That Do Not Coordinate
Delta Dental will pay benefits without regard to benefits paid by the following kinds of coverage:
- Medicaid
- Group hospital indemnity plans that pay less than $100 per day
- School accident coverage
- Some supplemental sickness and accident policies
How Delta Dental Pays As Primary Plan
When Delta Dental is primary, Delta Dental will pay the full benefit allowed by your contract as if you had no other coverage.
How Delta Dental Pays As Secondary Plan
- When Delta Dental is secondary, payments will be based on the balance left after the primary plan has paid. In no event will Delta Dental pay more than it would have paid as primary. For example, if the primary plan pays an amount higher than Delta Dental would have paid, no payment will be made by Delta Dental. If the primary plan pays less than Delta Dental allows, Delta Dental will pay the difference up to Delta Dental's allowed amount.
- Delta Dental will pay only for health care expenses that are covered by Delta Dental.
- Delta Dental will pay only if you have followed all of the procedural requirements, including care obtained from or arranged by your Dentist, Predeterminations, etc.
- Delta Dental will pay no more than the "allowable expenses" for the health care involved. If the allowable expense is lower than the primary plan's, Delta Dental will use the primary plan's allowable expense. That may be less than the actual bill.
Which Plan Is Primary?
To decide which plan is primary, Delta Dental has to consider both the coordination provisions of the other plan and which member of your family is involved in a claim. The primary plan will be determined by the first of the following, which applies:
- Non-coordinating Plan
If you have another group plan that does not coordinate benefits, it will always be primary.
- Employee
The plan, which covers you as an employee (neither laid off nor retired), is always primary.
- Children (Parents Divorced or Separated)
If the court decree makes one parent responsible for health care expenses, that parent's plan is primary.
If the court decree gives joint custody and does not mention health care, Delta Dental follows the birthday rule (see below).
If neither of those rules applies, the order will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.
- Children and the Birthday Rule
When your children's health care expenses are involved, Delta Dental follows the "birthday rule." The plan of the parent with the first birthday in a calendar year is always primary for the children. If your birthday is in January and your spouse's birthday is in March, your plan will be primary for all of your children.
However, if your spouse's plan has some other coordination rule (for example, a "gender rule" which says the father's plan is always primary), Delta Dental will follow the rules of that plan.
- Other Situations
For all other situations not described above, the order of benefits will be determined in accordance with the Ohio Insurance Department rule on Coordination of Benefits.
Coordination Disputes
If you believe Delta Dental has not paid a claim properly, you should first attempt to resolve the problem by contacting Delta Dental. Click here for details about the claims process.
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