Subrogation and Coordination of Benefits - Chapter 9, 2018 UnitedHealthcare Administrative Guide

Subrogation and Coordination of Benefits

Our benefit plans are subject to subrogation and COB rules.

  1. Subrogation —We have the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness to the extent permitted under state and federal law and the member’s benefit plan.
  2. Coordination of Benefits (COB) — COB is administered according to the member’s benefit plan and in accordance with law. We accept secondary claims electronically. To learn more, go to UHCprovider.com/edi > EDI Quick Tips for Claims > Secondary/COB or Tertiary Claims. You can also contact EDI Support at 800-842-1109 or UHCprovider.com > Contact Us > Technical Assistance > Electronic Data Interchange (EDI) Support.
  3.  Workers’ Compensation — In cases where an illness or injury is employment-related, workers’ compensation is primary. If you receive notification that the workers’ compensation carrier has denied a claim for services, submit the claim to us. It is also helpful to send us the worker’s compensation denial statement with the claim.

Medicare — If the care provider accepts Medicare assignment, all COB types coordinate up to Medicare’s allowed amount. Medicare Secondary Payer (MSP) rules dictate when Medicare pays secondary.

Other coverage is primary over Medicare in the following instances:

  • Aged Employees: For members who are entitled to Medicare due to age, commercial is primary over Medicare if the employer group has 20 or more employees.Disabled employees (Large Group Health Plan): For members who are entitled to Medicare due to disability, commercial is primary to Medicare if the employer group has 100 or more employees.

End-Stage Renal Disease (ESRD)
If a member has or develops ESRD while covered under an employer’s group benefit plan, the member must use the benefits of the plan for the first 30 months after becoming eligible for Medicare. After the 30 months, Medicare is the primary payer. However, if the employer group benefit plan coverage were secondary to Medicare when the member developed ESRD, Medicare is the primary payer and there is no 30 month period.

Continuation of Benefits — Consolidated Omnibus Budget Reconciliation Act (COBRA)
COBRA gives workers and their families who lose their health benefits have the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances, such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. COBRA generally requires group health plans sponsored by employers with 20 or more employees in the prior year to offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. Continuation coverage may be available to the member at group premium rates. Coverage benefits and limitations for COBRA members are identical to those of the group.

  • We are not responsible for initiating a terminated member’s election of continuation coverage.
  • Interested members should contact the subscriber’s Human Resources office for information on eligibility.
  • Members eligible for COBRA may elect to convert to an individual health plan, where available.

Additional information on COBRA is available at dol.gov > Topics > Continuation of Health Coverage - COBRA.

Coverage begins on the date that coverage would otherwise have been lost and ends at the end of the maximum period. It may end earlier if:

  • Premiums are not paid;
  • The employer ceases to maintain any group health plan;
  • After the COBRA election, the member obtained coverage with another employer-group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary. However, if the member obtains other group health coverage prior to electing COBRA , COBRA coverage may not be discontinued, even if the other coverage continues after the COBRA election;
  • If a beneficiary becomes entitled to Medicare benefits after electing COBRA. However, if Medicare is obtained prior to COBRA election, COBRA coverage may not be discontinued, even if the other coverage continues after the COBRA election.

COBRA specifies certain periods of time, that continued health coverage must be offered to qualified beneficiaries, COBRA does not prohibit plans from offering continuation health coverage that goes beyond the COBRA periods.

Note: In some cases, there may be an extensive period where a continuing member does not appear on the eligibility list. If this occurs, contact your network care provider account manager or provider advocate for assistance.