Coordination of Benefits and Subrogation Sample Clauses

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Coordination of Benefits and Subrogation. IPA and HMO shall establish and implement a system for coordination of benefits and subrogation, in accordance with those rules established under the HMO's policies and procedures and applicable federal and state laws. If known to IPA, IPA shall identify and inform HMO of Members for whom coordination of benefits and subrogation opportunities exist. HMO hereby authorizes IPA to seek payment, on a fee-for service basis or otherwise, from any insurance carrier, organization, or government agency which is primarily responsible for the payment or provision of medical services provided by IPA under this Agreement which can be recovered by reason of coordination of benefits, motor vehicle injury, worker's compensation, temporary disability, occupational disease, or similar exclusionary or limiting provisions, to the extent authorized by the applicable and not otherwise prohibited by law.
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Coordination of Benefits and Subrogation. Professional Provider agrees to and shall cause Practitioners to cooperate with Highmark’s coordination of benefits efforts consistent with a Member’s Plan Document and the Administrative Requirements. Professional Provider shall make efforts to collect and provide to Highmark other payor information as requested under established Highmark billing requirements. Professional Provider further agrees to and shall cause Practitioners to cooperate with Highmark or Health Plan in efforts to pursue subrogation claims against others where a person or entity other than Highmark or Health Plan has primary responsibility for payment.
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Coordination of Benefits and Subrogation. Pharmacy Benefit Manager will perform and bear the cost of any and all services and activities necessary to perform the services described under this Agreement. If the State or a third-party administrator notifies Pharmacy Benefit Manager that a Member has a primary insurer other than the Employee Plan, then Pharmacy Benefit Manager will pay Claims for such Member as a secondary payor other than as a primary payor. Pharmacy Benefit Manager does not assume responsibility for establishing coordination of benefits filing orders for subsequent coverages, nor responsibility for coordination of benefits investigational efforts, subrogation, or coordination with Worker’s Compensation. In addition, Pharmacy Benefit Manager will promptly provide the State, the Employee Plans, and their respective agents with such information as may be reasonably requested to pursue subrogation or reimbursement of Claims processed by Pharmacy Benefit Manager under this Agreement.
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Coordination of Benefits and Subrogation. 6.01 Coordination of Benefits in General (a) Benefits payable under this Plan for expenses of a covered person who is also covered under another group health plan or governmental program shall be coordinated so that the total amount payable from all plans shall not exceed 100 percent of covered Benefits or expenses actually incurred, whichever is the lesser amount. When this Plan is a secondary plan, this Plan shall provide Benefits for covered expenses that were not payable under the primary plan or any other health plan, subject to any co- payment, deductible, and coinsurance amounts, regardless of whether the primary plan actually meets its obligation to pay for covered expenses. In no event shall the benefits provided by this Plan exceed the benefits that would have been provided by this Plan as the primary plan. (b) If the Plan is secondary and the primary plan establishes to the satisfaction of the Board that it is unable to pay the claim in question, then the Plan may be in the sole discretion of the Board pay a portion or all of the claim that would ordinarily be a covered expense of the primary plan. (c) Notwithstanding the coordination of benefits provisions of this Article 6, to the extent that they are inconsistent with the coordination of benefits provisions with respect to any insured benefit set forth in the Summary Plan Description or any insurance contract, the provisions of the Summary Plan Description or insurance contract will control.
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Coordination of Benefits and Subrogation. Provider shall request information from Members regarding other payers which may be primarily responsible for Member’s Covered Services. Provider shall comply with Plan’s coordination of benefits rules. If Provider has or receives information on the identity of a responsible party for coordination of benefits, Provider must immediately provide that information to Plan. Provider shall pursue payment from other responsible payers and shall bill Plan only for Covered Services not payable by the primary payer. All payment amounts received from other primary payers for Covered Services shall be promptly credited against or deducted from billable amounts otherwise payable under this Agreement. Payments by Plan as a secondary payer, when
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Coordination of Benefits and Subrogation. ‌ Introduction‌ This Coordination of Benefits (COB) provision applies when you or your covered dependents have healthcare coverage under more than one plan. This plan follows the COB rules of payment issued by the Rhode Island Office of the Health Insurance Commissioner (OHIC) in Regulation 48, and the National Association of Insurance Commissioners (NAIC). From time to time these rules may change before a revised agreement can be provided. The most current COB regulations in effect at the time of coordination are used to determine the benefits available to you. When this provision applies, the order of benefit determination rules described below will determine whether we pay benefits before or after the benefits of another plan.
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Coordination of Benefits and Subrogation. Physicians Care shall be entitled to any amount Physicians Care collects from other insurers on account of IPA Services provided to Member Patients by IPA Physicians. The IPA shall cause IPA Physicians to cooperate with Physicians Care's coordination of benefits and subrogation policies and procedures.
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Coordination of Benefits and Subrogation. The IPA shall cause IPA Physicians to cooperate with coordination of benefits and subrogation policies and procedures established by MedServ or Physicians Care. Physicians Care shall not make any payment in excess of the amount Physicians Care would be obligated to make as if the primary payor. If Physicians Care pays as the primary payor and subsequently determines that another party is liable to make payments as primary payor, the IPA Physician agrees to remit to Physicians Care any excess payment. Physicians Care may set off against payments otherwise due the IPA Physician the amount of such excess payment. 14.
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Coordination of Benefits and Subrogation 
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Related to Coordination of Benefits and Subrogation

  • Coordination of Benefits i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

  • Retention of Benefits Union leave under the following four (4) sections will be unpaid. The Employer will maintain regular pay and ▇▇▇▇ the Union for the costs of the employee’s salary and benefits. If the Union member is part-time or casual, and the leave is greater than their normal work hours, the Employer will pay the employee for the full length of the leave requested by the Union. The Employer will ▇▇▇▇ the Union for these days as noted above. The Union will pay these invoices within twenty-eight (28) days. Union leave is not unpaid leave for the purposes of Article 22.02 [i.e. such leave will not affect the employee’s benefits, seniority or increment anniversary date].

  • Termination of Benefits Except as provided in Section 2 above or as may be required by law, Executive’s participation in all employee benefit (pension and welfare) and compensation plans of the Company shall cease as of the Termination Date. Nothing contained herein shall limit or otherwise impair Executive’s right to receive pension or similar benefit payments that are vested as of the Termination Date under any applicable tax-qualified pension or other plans, pursuant to the terms of the applicable plan.

  • Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates: 1.09.01 the date the member is no longer disabled from performing the duties of their regular position, or any alternative employment made available to the member by the City. 1.09.02 the date the member's Income Protection benefits have been expended. 1.09.03 the date the member dies.

  • Limitation of Benefits (a) Anything in this Agreement to the contrary notwithstanding, in the event it shall be determined that any benefit, payment or distribution by the Company or any of its direct and/or indirect subsidiaries to or for the benefit of Employee (whether paid or payable or distributed or distributable pursuant to the terms of this Agreement or otherwise, but determined without regard to any additional payments required under this Section 18) (such benefits, payments or distributions are hereinafter referred to as “Payments”) would, if paid, be subject to the excise tax imposed by Section 4999 of the Code (the “Excise Tax”), then, prior to the making of any Payments to Employee, a calculation shall be made comparing (i) the net after-tax benefit to Employee of the Payments after payment by Employee of the Excise Tax, to (ii) the net after-tax benefit to Employee if the Payments had been limited to the extent necessary to avoid being subject to the Excise Tax. If the amount calculated under (i) above is less than the amount calculated under (ii) above, then the Payments shall be limited to the extent necessary to avoid being subject to the Excise Tax (the “Reduced Amount”). The reduction of the Payments due hereunder, if applicable, shall be made by first reducing cash Payments and then, to the extent necessary, reducing those Payments having the next highest ratio of Parachute Value to actual present value of such Payments as of the date of the change of control, as determined by the Determination Firm (as defined in Section 18(b) below). For purposes of this Section 18, present value shall be determined in accordance with Section 280G(d)(4) of the Code. For purposes of this Section 18, the “Parachute Value” of a Payment means the present value as of the date of the change of control of the portion of such Payment that constitutes a “parachute payment” under Section 280G(b)(2) of the Code, as determined by the Determination Firm for purposes of determining whether and to what extent the Excise Tax will apply to such Payment. (b) All determinations required to be made under this Section 18, including whether an Excise Tax would otherwise be imposed, whether the Payments shall be reduced, the amount of the Reduced Amount, and the assumptions to be used in arriving at such determinations, shall be made by an independent, nationally recognized accounting firm or compensation consulting firm mutually acceptable to the Company and Employee (the “Determination Firm”) which shall provide detailed supporting calculations both to the Company and Employee. All fees and expenses of the Determination Firm shall be borne solely by the Company. Any determination by the Determination Firm shall be binding upon the Company and Employee. As a result of the uncertainty in the application of Section 4999 of the Code at the time of the initial determination by the Determination Firm hereunder, it is possible that Payments hereunder will have been unnecessarily limited by this Section 18 (“Underpayment”), consistent with the calculations required to be made hereunder. The Determination Firm shall determine the amount of the Underpayment that has occurred and any such Underpayment shall be promptly paid by the Company to or for the benefit of Employee, but no later than March 15 of the year after the year in which the Underpayment is determined to exist, which is when the legally binding right to such Underpayment arises.