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Atlantis Outpatient Centers


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Coordination of Benefits

1. General. You may be covered by two or more group health benefit plans. These programs may provide similar benefits. Should you have services covered by more than one plan, Atlantis will coordinate benefit payments with the other plan. In this case, one plan plays its full benefit as a primary benefit. The other plan pays secondary benefits. This prevents duplicate payments and overpayments. In no event shall payments exceed 100% of a charge.

In order to determine which plan is primary, certain rules have been established. Atlantis follows these rules. These rules apply whether or not you make a claim under both plans.

If Atlantis pays you more than you should have been paid under this provision, it has the right to recover the overpayment. Atlantis may recover the overpayment from you or any other person, insurance company, or other organization which gained from the overpayment. You must help ATLANTIS in recovering any overpayment. This help may mean filing claim forms with another company. It may mean endorsing checks over to ATLANTIS.

ATLANTIS has the right to decide which facts it needs in order to coordinate benefits. ATLANTIS may get needed facts from or give needed facts to any organization or person. ATLANTIS need not tell or obtain the consent of any person to do this, except as required by Article 25 of the New York State General Business Law. You must give ATLANTIS any facts it needs to process a claim and coordinate benefits.

2. Plan. A plan is a form of group coverage other than Medicaid on which these rules of coordination of benefits are allowed. A plan includes:

(a) Group insurance, group or group remittance subscriber contracts.

(b) Uninsured group coverage.

(c) Prepayment group coverage including HMOís, group practice and individual practice plans.

(d) Blanket contracts, except blanket school accident coverage or such coverage issued to a substantially similar group, where the policyholder pays the premium.

(e) The medical benefits coverage in group and individual mandatory automobile no-fault contracts.

3. Rules of Coordination. The rules for determining primary and secondary benefits are as follows:

(a) The plan covering you as an employee is primary before a plan covering you as a dependent.

(b) The plan of a parent whose birthday occurs first in the year is primary for dependent children covered under plans maintained by both parents. Birthday refers only to the month and day on which the parent is born and not the year. If both parents have the same birthday, the plan covering you for the longer time is primary. If the other plan does not have the rule discussed above but has a rule based upon the gender of the parent, that planís rule determines order of benefits.

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