Co-ordination of benefits refers to the process of managing payments when more than one coverage is in effect. The primary carrier will pay the majority of eligible expenses, and the secondary will absorb the lesser. The total reimbursement from both carriers will not exceed 100% of the expenses incurred.
On group insurance, In the case of the employee, the employer’s group plan is always primary. In the case of dependent children, the father’s plan is always primary (this can vary based on the company).
Calendar year versus Policy Year
Calendar year is the continuous period of time that begins January 1 and ends December 31. Policy Year commences on the effective date of the policy.
This is an illness or injury for which symptoms have been present or for which a member has received medical care/treatment or advice prior to the commencement of the policy.
Approval in advance by the Insurance Carrier for medically necessary covered services, subject to eligible charges.
This will be a listing of Physicians, hospitals, skilled nursing facilities or other healthcare providers who have contracted with the Carrier to provide care at an agreed price based on a Fee Guide.
This would be charges for the preparation, including cremation and return to the place of residence in the Bahamas of the remains of the deceased who was insured at the time of death.
In completing the required claim form, please ensure that the following items are indicated:
- Name of patient
- Type of Service (CPT code)
- Date of Service
- Charge for each service
- Diagnosis information (ICD-9 code)
- Physician’s stamp or signature
- Member’s signature is required
- A separate claim is required for each claimant
Claims must be submitted within three (3) months of the date of service. It is best to submit claims as soon as they are incurred.
Co-payments are those flat dollar amounts that must be paid by a member as a condition for receiving certain covered services. Co-insurance is a percentage of eligible charges that is the financial responsibility of the member.
This represents the limit of co-payments, deductible and co-insurance that must be paid by a member in a calendar year. Charges in excess of the eligible charges do not apply to the out of pocket maximum. On attainment of this limit, eligible charges are covered at 100%.
The amount of eligible expenses a member must pay each calendar year before the Company pays benefits. Once the stated number of family members (this differs by contract) have met the deductible in a calendar year, the deductible will be considered as having been met for other family members for that calendar year.
If a member does not meet the deductible, eligible charges for covered services received during October, November or December of that year will count towards that member’s deductible for the next year. (this applies to most carriers).