Order of submission (as per the Canadian Life & Health Insurance Association CLHIA)
The employee will always send their claims to their insurance carrier first
* If the employee has two group benefit plans, the one in which they work full time with, or the one with the earliest effective date will be the primary plan
* A retiree plan will be second to a group benefit plan
The spouse of the employee will send claims to their insurance carrier first
Any claim not paid in full by the first plan, can be sent to the spouse’s plan. Some carriers require the secondary claim to be submitted manually, and require a copy of the receipt, and explanation of benefits from the first payor.
* Some carriers allow for coordination of benefit / second payor claims to be submitted on line. The on-line claims feature is available for all major carriers; however, the process, timing and features differ. In all cases direct deposit must be subscribed to.
Claims for dependent children are sent to the plan of the parent who has the earlier birthdate (month and day) in the calendar year.
* For example, the parent who was born in March would be the first payor, vs the parent who was born in July.
* Or, if both parents share the same birthday, claims submission will be determined based on the alphabetical order of the parent’s first names.
Order of submission for Children of a Split Family
* 1st Carrier – The parent in which the child resides with full time
* 2nd Carrier – The Step-Parent in which the child resides with full time
* 3rd Carrier (if applicable) – The parent in which the child does not reside with full time
* 4th Carrier (if applicable) – The Step-Parent in which the child does not reside with full time
Total reimbursement for any claim cannot be more than 100% of the eligible expense.
Other types of Plans & Coordination
* Retiree plans
* Treaty plans
* Individual Benefit plans
* Government plans, such as the Alberta Child Benefit
* Senior Plan
* The order of submission will always be the same between two group plans
* Government plans are normally first payor
* Each insurance company has their own claims practices for COB claims