NY Manual
SHP Manual

New York Provider Manual
17.3 Time Frames for Claim Submission, Adjudication and Payment | 17.5 Explanation of Payment (EOP) / Electronic Funds Transfer (EFT) / Electronic Remittance Advice (ERA)

17.4 Coordination of Benefits (COB)

Coordination of benefits (COB) ensures that the proper payers are held responsible for the cost of healthcare services and is one (1) of the factors that can help hold down copayments and premiums. Healthfirst follows all standard guidelines for COB. Members are asked to provide information about other insurance plans under which they are covered.

Healthfirst is Always the Secondary Payer in the Following Circumstances

·     Workers’ compensation.
·     Automobile medical.
·     No-fault or liability auto insurance.

Healthfirst Does Not Pay for Services Provided Under the Following Circumstances When There is COB

·     The Department of Veterans Affairs (VA) or other VA facilities (except for certain emergency hospital services).
·     When VA-authorized services are provided at a non-VA hospital or by a non-VA provider.

The Following Applies to Healthfirst Medicare Plan Only

Healthfirst will use the same guidelines as Medicare for the determination of primary and secondary payer. As a result, Healthfirst is the secondary payer for all of the cases listed above as well as for the following: 

·     Most Employer Group Health Plans (EGHP).
·     Most EGHPs for disabled members.

All benefits payable under an EGHP in the case of individuals who are entitled to benefits solely or partly on the basis of end-stage renal disease (ESRD) during a period of thirty (30) months. (This applies to all services, not just to ESRD. If the individual entitlement changes from ESRD to over sixty-five [65] or disability, the coordination period will continue.)