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Coordination of Benefits

Coordination of Benefits

The following is a guide for handling situations involving coordination of patient insurance benefits per the rules as set forth in 2008 by the Commissioner of Insurance of Massachusetts:

Patient does not have private health insurance; or has MassHealth, Medicare, Medicaid or a fully self-funded ERISA-based health insurance plan:

PIP will pay up to $8,000 in medical expenses, lost wages, or replacement services. Once $8,000 is exhausted, further charges are submitted to the same insurer for payment out of any applicable MedPay benefits. If no MedPay benefits exist, charges remaining unpaid may then be submitted to MassHealth, Medicare, Medicaid or the ERISA plan.

Patient has private health insurance:

PIP will pay up to $2,000 in medical expenses, lost wages, or replacement services. Once $2,000 is exhausted, further charges are submitted to the private health insurer. The claimant and patient must comply with the requirements of the health insurance policy. If the health insurer denies payment for services that are not covered by the claimant’s health insurance policy, the claimant may submit unpaid charges to PIP for the remaining $6,000.

Patient has private health insurance and MedPay:

PIP will pay up to $2,000 in medical expenses, lost wages, or replacement services. Once $2,000 is exhausted, further charges are submitted to the private health insurer.

  • If the private health insurance policy contains deferral language, charges are submitted to MedPay after the exhaustion of $2,000 in PIP. Once MedPay benefits are exhausted, the claimant may submit unpaid charges to PIP for the remaining $6,000. Once all $8,000 is exhausted, further charges are submitted to the private health insurer.
  • If the private health insurance policy does not contain deferral language, charges are submitted to the private health insurer, pursuant to Example 2. If the health insurance carrier denies payment and PIP is not required to pay (i.e. because the patient failed to comply with the health insurance policy) unpaid charges may be submitted to MedPay.

You can find even more information about coordinating benefits at: http://www.mass.gov/ocabr/government/oca-agencies/doi-lp/2008-12-clarification-of-coordination-of.html

Questions about this or any other PIP issue? give us a call at (978) 745-7950 or email us at: info@pipcollect.com

Disclaimer

The information provided in this document is for informational purposes only and not for the purpose of providing legal advice. You should contact your attorney to obtain advice with respect to any particular issue or problem. Use of and access to this information does not create an attorney-client relationship between The Law Offices of PIP Collect, LLC and the user or reader. The opinions expressed at or through this document are the opinions of the individual author and may not reflect the opinions of the firm or any individual attorney.

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