Our benefit plans are subject to subrogation and coordination of benefits 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. For subrogation/reimbursement matters, contact:
11000 Optum Circle MN102-0300
Eden Prairie, MN 55344 subroreferrals.optum.com Fax: 1-800-842-8810
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 UHCprovider.com/edicontacts.
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 workers’ compensation denial statement with the claim.
4. 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:
If a member has or develops ESRD while covered under an employer’s group benefit plan, the member must use the benefits of the employer’s group 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.
COBRA provides continued group health benefits to workers and families who lost coverage. COBRA generally requires group health plans with employers who have 20 or more employees, in the prior year, to offer continuation of coverage in certain instances where coverage would end. This coverage is available at the group premium rates. Coverage benefits and limitations for COBRA members are the same to those of the group.
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:
COBRA specifies certain periods of time that continued health coverage must be offered. It does not prevent plans from offering more health coverage beyond the COBRA period.
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.