Coordination of benefits

To comply with Washington State Office of the Insurance Commissioner regulations, health plan carriers coordinate benefits so that when an individual has more than one Kaiser Permanente plan, each plan pays its share of the medical expenses.

If your patient is covered by two or more health plans, we can coordinate benefits with the other health plans to help the patient receive the full benefit of those plans. By coordinating benefits, we may be able to waive or reduce out-of-pocket expenses for covered services.

Dual Kaiser Permanente plans

When caring for a Kaiser Permanente member with dual Kaiser Permanente plans, identify the primary health plan following Washington Administrative Code Standards for Coordination of Benefits (WAC 284-51). If you are unsure which health plan is the primary health plan, contact the Provider Assistance Unit.

Kaiser Permanente as secondary carrier

If Kaiser Permanente is the secondary to another health plan, submit the claim to the primary health plan first. All Kaiser Permanente coverage and criteria requirements apply, regardless of whether Kaiser Permanente is the primary or secondary health plan.

When a member has primary insurance, the secondary plan may be required to waive the gatekeeper requirement when the primary plan's requirements have been met.

For FEHB Core and Self-Funded Core plans that follow the maintenance of benefits rule, the amount paid by the primary insurance is used to reduce the amount that Kaiser Permanente would pay as the secondary. Members must follow the network and authorization rules of their Kaiser Permanente plan for claim payment, even if it is not the primary plan. Members will be responsible for cost-shares determined by the plan.

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