Coordination of Benefits and Patient Share

Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits.

This article is meant to assist physicians and other professional providers, and facilities in understanding the coordination of benefits clause from the contracting perspective.

The information contained in this article applies to member's health benefit policies issued by Blue Cross and Blue Shield of Texas (BCBSTX). Please note, some Administrative Services Only (self-funded) groups may elect not to follow the general Coordination of Benefit rules of BCBSTX.

When the member's health benefit policy is issued by another Blues plan, also known as the HOME plan, the Coordination of Benefit provision is administered by that HOME plan, not BCBSTX. Therefore, the member's HOME plan health benefit policy will control how Coordination of Benefits is applied for that member.

Per the BCBSTX coordination of benefits contract language, the physicians and other professional providers, and facilities have agreed to accept the BCBSTX allowable amount (as defined by the contract) less any amount paid by the primary insurance carrier.

What does this mean for you?

Once the claim has been processed by BCBSTX as the secondary carrier, the only patient share amount that may be collected from the member is the amount showing on the BCBSTX Provider Claim Summary.

The primary carrier does not take into account the member's secondary coverage. This means that once the claim is processed as secondary by BCBSTX, any patient share amount shown to be owed on the primary carrier's explanation of benefits is no longer collectible.

If you have questions regarding a specific claim, please contact Provider Customer Service at (800) 451-0287 to speak with a Customer Advocate.