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Section 8: Coordination of Benefits and Third Party Liability
Coordination of benefits (COB) applies to members who are covered by more than one medical coverage plan or program. Examples of COB include secondary insurance through an employer sponsored health insurance plan, motor vehicle accident insurance, or worker’s compensation coverage.
Third party liability (TPL) occurs when members are injured as a result of an accident when another party may be liable for the payment of the member’s medical claims. The most common types of TPL cases are motor vehicle accidents, workers’ compensation injuries, work-related or occupational injuries, and slip-and-fall injuries.
Because CMS and Commonwealth Care Alliance are payers of last resort, the automobile accident insurance, workers’ compensation insurance, and general liability insurance are primary payers for these members’ claims related to the accident.
Under TPL, Commonwealth Care Alliance is the secondary payer of coverage. Commonwealth Care Alliance will not make payment on related claims until the TPL case has reached a conclusion or settlement. For all claims relating to a TPL case, providers should submit to Commonwealth Care Alliance, the claim with the notice of settlement from the attorney representing the member within 60 days from the settlement date of the case. Claims submitted without a notice of settlement will be denied.