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Coordination of Benefits

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Who pays first when there’s duplicate coverage?

When your patient has more than one insurance provider, we follow Coordination of Benefits (COB) standards to determine if we’re the primary or secondary payer. These are standards set by the National Association of Insurance Commissioners (NAIC).

We coordinate benefits payable for covered services with benefits payable by other plans, consistent with state law. Claims submitted to SWHP for secondary payment must include the primary carrier’s Explanation of Benefits (EOB).

Please note that if we’re reimbursing services as a secondary carrier, our policies and procedures regarding referral, prior authorization, and prior approval must still be followed.

If you have any COB questions, or need clarification on how to coordinate benefits, give us a call.

Medicare Coordination of Benefits Guidelines

If member is covered by Medicare and is: Primary Secondary
  • Age 65 or over
  • An actively working subscriber
  • Employer group with 20 or more employees
Scott and White Health Plan Medicare
  • Age 65 or over
  • An actively working subscriber is actively working
  • Employer group with fewer than 20 employees
Medicare Scott and White Health Plan
  • Age 65 or over
  • A retired subscriber
Medicare (as of retirement date) Scott and White Health Plan
  • Age 65 or over
  • On Medicare due to disability
  • An actively working subscriber
  • Employer group with 100 or more employees
Scott and White Health Plan Medicare
  • Age 65 or over
  • On Medicare due to disability
  • An actively working subscriber
  • Employer group with fewer than 100 employees
Medicare Scott and White Health Plan
  • Age 65 or over
  • A subscriber not actively working
Medicare Scott and White Health Plan