Orchard - Unchanged

Coordination of Benefits

When PEHP is the primary plan, its eligible benefits are paid before those of the other health benefit plan and without considering the other health plan’s benefits. When PEHP is the secondary plan, its eligible benefits are determined after those of the other health benefit plan and may be reduced to prevent duplication of benefits.

When secondary, PEHP calculates the amount of eligible benefits it would normally pay in the absence of the primary plan coverage, including deductible, co-payments, co-insurance, and the application of credits to any policy maximums. PEHP then determines the amount the member is responsible to pay after the primary carrier has applied its allowed contracted amount. PEHP will then pay the amount of the member’s responsibility after the primary plan has paid, up to the maximum amount it would have paid as the primary carrier. In no event will PEHP pay more than the member is responsible to pay after the primary carrier has paid the claim. Only member responsibility amounts remaining after PEHP processes claims as the secondary payor will be applied to the deductible, co-payment, co-insurance, and out of pocket accumulators.

Medical and pharmacy claims are subject to all plan provisions as described in the master policy, including, but not limited to, preauthorization/pre-notification requirements, benefit limitations, step therapy requirements, quantity level rules, etc., regardless of whether PEHP is the primary or secondary payer.

Medicare COB

PEHP receives Medicare COB claims directly from Medicare. You should no longer need to submit Medicare COB claims directly to PEHP. Medicare COB claims sent to PEHP before 30 days from the day Medicare paid the claim will automatically be rejected by PEHP. We recommend you wait 10 days from the time Medicare made payment to check claims status online.