Utah Admin. Code R590-131-5 - Rules for Coordination of Benefits
When an enrollee is covered by more than one plan, the rules for determining the order of benefit payments are as follows:
(1) The primary plan shall pay or provide
benefits as if a secondary plan does not exist.
(2) If the primary plan is a closed panel
plan and the secondary plan is not a closed panel plan, the secondary plan
shall pay or provide benefits as the primary plan, except for an emergency
service or an authorized referral that is paid by the primary plan.
(3) If an enrollee is covered by more than
one secondary plan, the order of benefits is determined using Section
R590-131-6.
(4)
(a) Except as provided in Subsection (4)(b),
a plan that does not contain a COB provision consistent with this rule is the
primary plan unless both plans state that the conforming plan is
primary.
(b) Supplemental coverage
that is obtained through membership in a group may be excess to a plan with a
basic package of benefits.
(i) Supplemental
coverage includes:
(A) major medical coverage
that is superimposed over a base plan providing hospital and surgical expense
benefits; and
(B) insurance type
coverage that is written in connection with a closed panel plan to provide
out-of-network benefits.
(ii) Supplemental coverage does not include a
non-conforming plan.
(5) Consideration of benefits paid or
provided by another plan may only occur when the plan is secondary to the other
plan.
Notes
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