Change to Coordination of Benefits Claims

Monday, Mar 30, 2020

Effective March 31, 2020, PBC has aligned with the Canadian Life and Health Insurance Association guidelines regarding coordination of benefits reimbursement.

At Pacific Blue Cross (PBC), we take health and wellness of British Columbians very seriously. We work hard to ensure the health and dental plans we offer are sustainable and provide you security for today and tomorrow.

We’d like you to be aware that PBC is introducing changes to the eligible amount when it comes to coordinating benefits across multiple plans.

Effective March 31, 2020, PBC has aligned with the Canadian Life and Health Insurance Association guidelines regarding coordination of benefits reimbursement. This is not a change to your health benefits plan coverage and all benefit levels remain the same.

This change impacts how claims are processed by ensuring Reasonable and Customary (R&C) claim limits are followed when coordinating reimbursement between benefit plans. 

Coordination of benefits reimbursement means that there is more than one plan paying towards a claim. Under the new process, if another benefit plan has already reimbursed a claim up to PBC’s R&C limit, no additional reimbursement will be eligible under your plan.  The intent is to ensure claims are paid to the R&C limit, regardless if one or more carriers are involved.

You’re receiving this message because our records indicate that your Municipal Pension Plan has paid a claim in the past as the secondary payor, meaning this plan paid a portion that your primary insurance didn’t cover.

To give you a better understanding of this change, here are some examples that illustrate the difference in payment with future claims when this plan is the secondary payor:

Claim Example 1: Dental | White Filling

  • Submitted Cost is $238
  • Primary insurance paid $200
  • PBC plan is secondary payor.  When white fillings are billed, Plan Design covers at the price of an amalgam (silver) filling.

 

  Amount Claim will Coordinate to… Submitted claim amount Primary Insurer pays PBC pays Member pays
Old Method $214 Plan Design Amount
(Plan Design is based on Dental fee guide pricing for amalgam (silver) filling)
$238 $200 $14 $24
New Method $238      Eligible Amount
(Eligible amount is based on plan Dental fee guide pricing – the R&C- for white filling
$238 $200 $38 $0

 

Old method   | Member’s portion is $24, as the two plans paid $214 of the $238 charge

New method | Member’s portion is $0, as the two plans paid the $238 claim in full, which is the price in the dental fee guide

Claim Example 2: Health | Massage Therapy 60 mins

  • Submitted Cost is $120
  • Primary insurance paid $110
  • PBC plan is secondary payor

 

   Amount Claim will Coordinate to… Submitted claim amount Primary Insurer pays PBC pays Member pays
Old Method $120      Amount Billed by Practitioner $120 $110 $10 $0
New Method $110      Eligible Amount
(Eligible Amount is based on the PBC R&C limit for the service)
$120 $110 $0 $10

 

Old method   | Member’s portion is $0, as the two plans paid the $120 claim in full

New method | Member’s portion is $10, as the primary insurer already paid the full eligible amount of $110, which is the R&C limit for Massage

Questions?

  • More information regarding reasonable and customary limits
  • To find out more about how this change may impact your claims, contact PBC at 604 419-2000 or 1 877 722-2583.