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Which benefit provider pays first?

The following example is for illustrative purposes only. Available coverage and claim limits may differ from your current level of coverage.

Jane, an ASEBP covered member, received a therapeutic massage and was charged a total of $60. Her Extended Health Care benefit plan will cover $50 per visit to a yearly maximum of $400. Jane's husband John also has a plan that covers the same service for $40 per visit to a yearly maximum of $400. Neither of them have reached their yearly maximums. How can they get maximum reimbursement of these expenses and what is the proper way to submit the claim?

If the products/services are received by the ASEBP covered member

As an ASEBP covered member, Jane sends her claim totaling $60 to ASEBP for the massage she received (ASEBP is first payer for her claims).

  1. She sends a completed claim form and the original receipts (she takes some photocopies because she'll need them later). ASEBP adjudicates the claim and, in the example above, reimburses $50. ASEBP also provides Jane with an Explanation of Benefits (EOB).
  2. John can then submit the remaining expenses to his benefit plan using a completed claim form, a photocopy of the receipt and the ASEBP Explanation of Benefits. John's plan will then adjudicate the claim and, in the example above, reimburse the outstanding $10.

If the products/services are received by a non-ASEBP covered member

As a dependent of an ASEBP covered member with other coverage, ASEBP is second payer for your claims. That means that you must first submit any claim to your primary health benefits carrier before sending any outstanding balance to ASEBP.

Using the same example from above, when the service is received by John, the claim goes to his plan first:

  1. John submits a completed claim form, the original receipts and remembers to take copies. John receives an EOB and a reimbursement of $40.
  2. Jane then submits a completed claim form, along with the EOB and a photocopy of the receipt to ASEBP to be reimbursed the remaining $20 of John's claim.

Please Note: As part of our ongoing effort to ensure that claims submitted by covered members are paid by ASEBP correctly, claims that are first sent to ASEBP when another carrier should be paying first will be returned to you for submission under the other plan starting September 1, 2004. Once the other carrier has paid its portion, any unpaid balance can be submitted to ASEBP.

Correct submission of claims will not reduce your reimbursement. It will help to ensure ASEBP is not over-paying for claims that are the responsibility of another plan. Referring to the situation described above, we can see in the table below that Jane and John are reimbursed the same amount.

Claim
Details

Cost/Reimbursement

ASEBP as 1st payer

ASEBP as 2nd payer

Total Charges $60
(Jane's massage)
$60
(John's massage)
ASEBP Pays $50 $20
Other Coverage Pays $10 $40
Total Reimbursement $60 (100% of the cost) $60 (100% of the cost)

Please note that, depending on what coverage is provided by your employer, and how much of that coverage you have used during the year, you may or may not have all the coverage mentioned here.