Coordination of benefits if you have two health plans

Coordination of benefits is the process by which, when you have more than one health plan, the primary plan pays the claim for medical services and the secondary plan pays the copays, deductibles and coinsurance the primary plan did not cover. Done right, you should not have to pay out of pocket or request your own reimbursement.

It applies to any patient, insured person or consumer covered by two or more health plans, including someone who has a private health plan plus the Government Health Plan of Puerto Rico. It is your obligation to inform participating providers of all the health plans you hold.

• Informing and providing participating providers with information about all the health insurance plans you hold at the time you request or need a medical service.Verified against the official source
• Confirming which is your primary plan and which is secondary. If you have the Government Health Plan of Puerto Rico plus a private plan, the Government Plan is always the secondary payer.Verified against the official source

• Proof of all the health plans you have: insurance cards, policy or subscriber numbers for each plan. The law does not publish a specific coordination form; that process happens between the provider and the insurers.

1. 1

   Step 1: Give your provider information on all your plans

   Before or at the time of service, inform the participating provider about each health plan you have. Without that information, coordination cannot begin.

2. 2

   Step 2: Do not accept the service being conditioned on you seeking your own reimbursement

   The law orders the Insurance Commissioner to prohibit by regulation participating providers from refusing to coordinate benefits, or from conditioning service on you handling the reimbursement with the insurer.

3. 3

   Step 3: Remember the responsibility is shared, with a 30-day deadline

   Health insurance organizations, their intermediaries and participating providers have the joint responsibility to process the coordination of benefits, with a maximum of 30 days from when they receive all necessary information and documentation.

4. 4

   Step 4: If coordination is obstructed, file a complaint

   If a provider refuses to coordinate, or an insurer, third-party administrator or intermediary obstructs or refuses without valid justification to cooperate, you can file an administrative complaint with the Department of Health under Article 17 of the Patient's Bill of Rights and Responsibilities.

The complaint is filed with the Department of Health. The Department will determine whether the matter falls under its jurisdiction or belongs to the Insurance Commissioner or the Health Insurance Administration (ASES), and will refer it accordingly.

• Paying the full deductible, copay or coinsurance and then requesting your own reimbursement from the second plan: the law places that responsibility on the provider and the insurers, not on you.
• Assuming your private plan automatically pays first if you also have the Government Health Plan: the Government Plan is always the secondary payer, never the primary one.
• Not informing your provider about all your plans: without that information, coordination cannot begin.
• Accepting a provider conditioning service on you handling the reimbursement yourself: that is exactly what the law seeks to prohibit by regulation.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov