Coordination of benefits

What is coordination of benefits (COB)?

If you and your dependents are covered for extended healthcare and/or dental benefits under more than one plan, your reimbursement will be coordinated following insurance industry standards. The maximum amount that you can receive from all plans for eligible expenses is 100% of actual expenses. 

The plan that does not contain a COB clause is always considered to be the first payor and therefore pays benefits before a plan which includes a coordination of benefits clause. 

For dental accidents, extended healthcare benefits with dental accident coverage provide reimbursement before dental benefits. 

Where both plans contain a COB clause, claims must be submitted in the order described below. 

How does coordination of benefits work?

Claims for you and your spouse should be submitted in the following order: 

  1. The plan where the person is covered as an employee. If the person is an employee under more than one plan, the following order applies:
    1. The plan where the person is covered as an active full-time employee.
    2. The plan where the person is covered as an active part-time employee. 
    3. The plan where the person is covered as a retiree.
  2. The plan where the person is covered as a dependent (for example, if you are covered as a dependent under your spouse's plan).

Claims for a dependent child should be submitted in the following order: 

  1. The plan where the child is covered as an employee. 
  2. The plan where the child is covered under a student health or dental plan provided through an educational institution.
  3. The plan of the parent with the earlier birthdate (month and day) in the calendar year. For example, if your birthday is May 1 and your spouse's birthday is June 5, you must claim under your plan first.
  4. The plan of the parent whose first name begins with the earlier letter in the alphabet, if the parents have the same birthdate. 

The above order applies in all situations except when parents are separated/ divorced and there is no joint custody of the child, in which case the following order applies:

  1. the plan where the child is covered as an employee.
  2. the plan where the child is covered under a student health or dental plan provided through an educational institution.
  3. the plan of the parent with custody of the child.
  4. the plan of the spouse of the parent with custody of the child.
  5. the plan of the parent not having custody of the child.
  6. the plan of the spouse of the parent not having custody of the child.

Expenses not covered by the first benefit may be eligible for some reimbursement under the other benefit.

Coordination of benefits information is gathered at the time of each claim submission. When submitting each claim with GreenShield, members will be asked if they have any other group insurance coverage. After the first benefit payor has processed your claim, members will receive an explanation or statement of benefits for that claim. Members can submit a claim for the remaining amount to their secondary plan and it will be paid according to the coverage of that plan. If you and your spouse are both with GreenShield, you only need to submit one claim form and GreenShield will coordinate your benefits for you. 

How does coordination of benefits work when both spouses work for the University and have benefits coverage?

When submitting claims online, please ensure that you and your spouse have both registered with GreenShield+ and have accepted the online agreement. This action is required for automatic coordination of benefits to occur.

Step 1: Whoever incurs the claim must sign in to their GreenShield+ account and submit the entire expense as the first step. 

Step 2: You will then be asked if there is secondary coverage, and if secondary coverage is with GreenShield.  

Step 3: You will be prompted to provide your spouse’s GreenShield Benefits ID number (See example below)

For dependent children, the plan of the parent whose birthdate (month and day) occurs earliest in the calendar year, claims must be submitted under this plan. As like above, the member will be prompted if other coverage and if GreenShield, they will indicate spouse’s GreenShield Benefit ID Number.

Example:

  • Michael’s GreenShield Benefits ID number is WTL123456. 
  • Jessica’s GreenShield Benefits ID number is WTL456789.
  • Michael’s Dependent GreenShield Benefits ID number under Jessica’s coverage is WTL456789-01
  • Jessica’s Dependent GreenShield Benefits ID number under Michael’s coverage is WTL123456-01

Michael is submitting a benefits claim for massage in the amount of $100 using his GreenShield benefit ID number WTL123456. During the claim process, it indicates that he has a second payor for benefits coverage through WTL456789 (Jessica's Benefits ID number).

This COB will enable GreenShield to automatically adjudicate the claim under both plans without having to submit the balance separately under Jessica’s plan.

IMPORTANT:

Please ensure that you and your spouse have both registered with GreenShield+ and have accepted the online agreement.

Please remember to use capital letters / upper case for the “WTL” in your GreenShield member ID number. If you use a lower case “wtl”, GreenShield’s claims system will not recognize your member ID number accurately.