PO Box91059 /
Seattle, WA 98111-1059

COORDINATION OF BENEFITS FORM

Please complete this form if you and/or your enrolled family members have additional health coverage.
By completing and returning this form, LifeWise Health Plan of Oregon will be able to process your claims in a timely and accurate manner.
Refer to the back of this form for answers to the most frequently asked coordination of benefits questions.
If you require assistance in completing this form, please contact your employer or the LifeWise Customer Service Department at 1-800-596-3440.
1. /

INSURANCE INFORMATION

Employee Name / Today’s Date
Employee’s Mailing Address / Employee’s ID Number
City / State / ZIP / Group Number
2. /

MEDICARE FOR EMPLOYEE AND ALL DEPENDENTS

Is any person applying for coverage covered by Medicare? / No / Yes, please complete the following:
Name / Medicare ID #
Effective Date: / Part A / Part B / Reason: Age Disability End Stage Renal Disease
Name / Medicare ID #
Effective Date: / Part A / Part B / Reason: Age Disability End Stage Renal Disease
3. / OTHER COVERAGE FOR ENROLLING EMPLOYEE (MEMBER) AND all DEPENDENTS
A. / Will any person applying for coverage be covered under another plan after the coverage with this plan begins? No Yes, complete the following:
Other Plan Name / Other Plan Group Number
Medical / Vision / Outpatient Prescription Drug / Dental
Date Coverage Began / Member ID # / Member Name
Other Plan Phone Number / ( ) - / Policy covers: Member Spouse Dependent Children

B.

/ If any dependent children are covered under another plan and the natural parents are divorced or separated, State regulations require that we ask you for the following information:
Child’s Last Name / First Name / Middle Initial / Name of Person with Custody / Relationship to Child Listed / Name of Person with Financial Responsibility for Health Coverage / Relationship to Child Listed / Name of Other Coverage Provided
4. / QUESTIONS AND ANSWERS TO HELP YOU UNDERSTANDCOORDINATION OF BENEFITS

What is Coordination of Benefits (COB)?

COB is two or more group health plans (including Medicare Secondary Payer) working together to share the cost of health care expenses.

Why do we coordinate benefits?

Oregon insurance regulations allow health insurance companies to coordinate benefits. These regulations allow us to keep the cost of your health care coverage as low as possible by avoiding payment of more than the total charge of bill(s) submitted. These rules identify one plan as “primary” (this plan pays first), and the other plan as “secondary” (this plan pays second).

Who do I submit my bill(s) to first?

  • Send your bills to your employer's health insurance carrier first.
  • The spouse of the employee will submit to the other plan first and to LifeWise second.
  • If the patient is a dependent child, submit to the parent’s plan whose birthday falls earliest in the year.

Example: mother’s birth date is 8/16 and father’s birthdate is 4/24, then submit to the father’s plan first.

  • If the parents of the dependent are divorced or legally separated, refer to your employee benefit booklet ("What If I Have Other Coverage" section).
  • If you have two LifeWise plans, submit each bill with both member identification numbers and group numbers.
  • If you are a member with more than one group health care plan, the plan that has been in effect the longest is primary. Submit bill(s) to the primary health carrier first.
  • Retiree plans may require non-retiree coverage to be primary.

How do we coordinate benefits?

  • When we receive your bill(s), we determine which health insurance company will process your claim first.
  • If you submit your bill(s) with the amount paid by your other health insurance company, a copy of their denial or an Explanation of Benefits, we will use this information to promptly process your claim.
  • If we do not receive this information with your bill(s), we will contact your other health insurance company to obtain the information needed to process your claim.

When do I receive a “Coordination of Benefits Form”?

  • When we have conflicting, incomplete or outdated information, you will receive a Coordination of Benefits Form.
  • When your other coverage cancels, we need new coverage information.

5. / IMPORTANT REMINDERS
  • When we request COB information, please return the request as soon as possible to assure prompt processing of your claim.
  • Always keep your health care providers (Doctor, Dentist, etc.) updated with your correct health care coverage information.
  • LifeWise will coordinate benefits for medical, outpatient prescription drug, vision and/or dental coverage.