THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS Clause Samples

The Third Party Liability and Coordination of Benefits clause establishes how responsibility for payment is determined when multiple parties or insurance policies could cover the same claim. In practice, this clause outlines the process for identifying other sources of coverage, such as auto insurance or workers’ compensation, and sets rules for how benefits are coordinated to prevent duplicate payments. Its core function is to ensure that claims are paid appropriately without overcompensation, thereby reducing the risk of double recovery and clarifying the order in which different insurers or responsible parties must pay.
THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 8.4.1 Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay all or part of the Health Care expenses of the Member. 8.4.1.1 Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for all CMO plan Members, including PeachCare for Kids® Members. 8.4.1.2 The Contractor shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to CMO plan Members. To the extent permitted by State and federal law, the Contractor shall use Cost Avoidance processes to ensure that primary payments from the liable third party are identified, as specified below. 8.4.1.3 If the Contractor is unsuccessful in obtaining necessary cooperation from a Member to identify potential Third Party Resources after sixty (60) Calendar Days of such efforts, the Contractor may inform DCH, in a format to be determined by DCH, that efforts have been unsuccessful.
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 8.4.1 Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay all or part of the Health Care expenses of the Member. 8.4.1.1 Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for all CMO plan Members, including PeachCare for Kids™ Members. 8.4.1.2 The Contractor shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to CMO plan Members. To the extent permitted by State and federal law, the Contractor shall use Cost Avoidance processes to ensure that primary payments from the liable third party are identified, as specified below. 8.4.1.3 If the Contractor is unsuccessful in obtaining necessary cooperation from a Member to identify potential Third Party Resources after sixty (60) Calendar Days of such efforts, the Contractor may inform DCH, in a format to be determined by DCH, that efforts have been unsuccessful. 8.4.2 Cost Avoidance 8.4.2.1 The Contractor shall cost avoid all Claims or services that are subject to payment from a third party health insurance carrier, and may deny a service to a Member if the Contractor is assured that the third party health insurance carrier will provide the service, with the exception of those situations described below in Section 8.4.2.2. However, if a third party health insurance carrier requires the Member to pay any cost-sharing amounts (e.g., co-payment, coinsurance, deductible), the Contractor shall pay the cost sharing amounts. The Contractor’s liability for such cost sharing amounts shall not exceed the amount the Contractor would have paid under the Contractor’s payment schedule for the service. 8.4.2.2 Further, the Contractor shall not withhold payment for services provided to a Member if third party liability, or the amount of third party liability, cannot be determined, or if payment will not be available within sixty (60) Calendar Days. 8.4.2.3 The requirement of Cost Avoidance applies to all Covered Services except Claims for labor and delivery, including inpatient hospital care and postpartum care, prenatal services, preventive pediatric services, and services provided to a dependent covered by health insurance pursuant to a court or...
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 213 11.1 Agent of the STATE. 213 11.2 Third Party Recoveries. 213 11.3 Coordination of Benefits. 214 11.4 Reporting of Recoveries. 215 11.5 Causes of Action. 215 11.6 Determination of Compliance. 215 Article. 12 Governing Law, Jurisdiction and Venue. 216 Article. 13 Compliance with State and Federal Law. 216 13.1 Constitutions 216 13.2 Prohibitions Against Discrimination. 216 13.3 State Law. 217 13.4 Medicaid Laws. 217 13.5 Environmental Requirements. 217 13.6 Energy Efficiency Requirements. 217 13.7 Anti-Kickback Provisions. 217 13.8 ▇▇▇▇▇-▇▇▇▇▇ Act. 217
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker's compensation) or program, that is, or may be, liable to pay all or part of the Health Care expenses of the Member.
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 202 11.1 Agent of the STATE 202 11.2 Third Party Recoveries. 202 11.3 Coordination of Benefits. 203 11.4 Reporting of Recoveries. 204 11.5 Causes of Action. 204 11.6 Determination of Compliance. 204 Article. 12 Governing Law, Jurisdiction and Venue. 205 Article. 13 Compliance with State and Federal Laws. 205 13.2 State Law. 206 13.3 Medicaid Laws. 206 13.4 Environmental Requirements. 206 13.5 Energy Efficiency Requirements. 206 13.6 Anti-Kickback Provisions. 206 13.7 ▇▇▇▇▇-▇▇▇▇▇ Act. 206 13.8 Contract Work Laws. 206 13.9 Regulations about Inventions. 207 13.10 Prohibition on Weapons. 207 Article. 14 Information Privacy and Security. 207 14.1 HIPAA Compliance. 207 14.2 Business Associate and Trading Partner. 207 14.3 Duties Relating to Protection of Information. 208
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 164 11.1 Agent of the STATE. 164
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THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS. 221 10.1 Agent of the STATE 221 10.2 Prompt Resolution of TPL Cases. 221 10.3 Third Party Recoveries. 221‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌‌ 10.3.2 Cost Benefit. 222‌ 10.3.3 Retention of Recoveries. 222 10.4 Coordination of Benefits. 223
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Related to THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS

  • 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.

  • 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.

  • Mitigation; Exclusivity of Benefits (a) The Executive shall not be required to mitigate the amount of any benefits hereunder by seeking other employment or otherwise, nor shall the amount of any such benefits be reduced by any compensation earned by the Executive as a result of employment by another employer after the Date of Termination or otherwise. (b) The specific arrangements referred to herein are not intended to exclude any other benefits which may be available to the Executive upon a termination of employment with the Employers pursuant to employee benefit plans of the Employers or otherwise.

  • Loss of Benefits Employees who are separated from the service by a discharge under other than honorable conditions, bad conduct, or dishonorable discharge shall not be entitled to any of the benefits of Section 3 through Section 9 of the Article (relating to military leaves without pay) except such vested rights as they may have acquired thereto by virtue of payments made into their retirement accounts.

  • Duplication of Benefits Grantee shall not carry out any of the activities under this Agreement in a manner that results in a prohibited duplication of benefits as defined by Section 312 of the ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155) and in accordance with Section 1210 of the Disaster Recovery Reform Act of 2018 (division D of Public Law 115-254; 132 Stat. 3442), which amended section 312 of the ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ Disaster Relief and Emergency Assistance Act (42 U.S.C. 5155). In consideration of Grantee’s receipt or the commitment of CRF funds by Florida Housing, Grantee hereby assigns to Florida Housing all of Grantee’s future rights to reimbursement and all payments received from any grant, subsidized loan or any other reimbursement or relief program related to the basis of the calculation of the portion of the funds committed to the Grantee under this Agreement and determined to be a Duplication of Benefits (DOB). Any such funds received by the Grantee shall be referred to herein as “additional funds.” Grantee agrees to immediately notify Florida Housing of the source and receipt of additional funds received by the Grantee that are determined to be a DOB. Grantee agrees to reimburse Florida Housing for any additional funds received by Grantee if such additional funds are determined to be a DOB by Florida Housing, the Federal awarding agency or an auditing agency.