Читать книгу Dental Letters: Write, Blog and Email Your Way to Success with CD-ROM - American Dental Association - Страница 21

Date

Patient Street Address City, State Zip

Dear Patient:

I understand that you have some questions regarding the coordination of benefits between two insurance plans. The term coordination of benefits (COB) applies to patients covered by more than one dental plan. For example, you may be covered by your employer’s plan and your spouse’s plan. When a patient has coverage under two or more group dental plans, there may be confusion as to how benefits are determined.

Certain rules are usually used when determining your benefits. There is no guarantee that any of the plans will pay for your services. It is important to consult your own plan for details regarding your coordination of benefits and coverage.

The following points should be considered when determining your coordination of benefits:

1 The coverage from both plans should be coordinated so that you or your dependent receives the maximum allowable benefit from each plan.

2 The aggregate benefit should be more than that offered by any of the plans individually, allowing duplication of benefits up to the full fee for the dental services received.

3 The plan that covers you first is your primary plan (most likely your employer-provided plan); all other plans are secondary. Secondary plans should only consider the benefits they have directly provided on your behalf when determining the balance of your dental benefits.

4 The secondary plan should use this benefit to pay up to 100 percent of your covered expenses during the claim period.

5 At the end of each claim determination, the secondary plan should provide you and the plan purchaser with a status report of claims paid and the remaining benefit.

6 When the patient is your dependent child, and the child is covered by two insurance plans, the plan of the parent whose birthday occurs first in a calendar year should be considered as primary.

7 When a determination cannot be made in accordance with “f” above, the plan that has covered the patient for the longer time should be considered as primary.

8 When one of the plans is a medical plan and the other is a dental plan, and a determination cannot be made in accordance with the above, the medical plan should be considered as primary.

Coordination of benefits can be difficult to understand. Please feel free to contact us [office number] if you have any questions.

Sincerely,

Dentist