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Coordination of Benefits Form UT SELECT A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

How to fill out coordination of benefits form

How to fill out coordination of benefits form:

1. Gather all necessary information, such as the primary insurance policy details, including the policyholder's name, plan ID, and group number.
2. Provide the secondary insurance policy information, including the policyholder's name, plan ID, and group number.
3. Indicate the order of benefits by specifying which policy is primary and which is secondary. This will determine the order in which the insurance companies will process the claims.
4. Fill in any additional information required, such as the effective dates of the policies and any limitations or restrictions that may apply.
5. Review the form for accuracy and completeness before submitting it.

Who needs coordination of benefits form:

1. Individuals who have multiple insurance policies, such as employer-sponsored health insurance along with a separate individual policy, may need a coordination of benefits form.
2. Dependents who are covered by more than one insurance plan, such as children covered under both parents' policies, may also require a coordination of benefits form.
3. Individuals who are eligible for coverage under Medicare and another insurance plan may need to complete a coordination of benefits form to ensure proper claims processing.

For pdfFiller’s FAQs

What is coordination of benefits form?

Coordination of benefits form is a document that is used in insurance claims to determine the primary payer when a person is covered by more than one insurance plan.

Who is required to file coordination of benefits form?

The individuals who are required to file coordination of benefits form are those who have multiple insurance coverage, such as being covered under both their employer's plan and their spouse's plan.

How to fill out coordination of benefits form?

To fill out coordination of benefits form, you will need to provide information about your primary insurance plan, secondary insurance plan, and any other relevant details on the form. It is important to accurately complete all sections and include any requested supporting documentation.

What is the purpose of coordination of benefits form?

The purpose of coordination of benefits form is to facilitate the proper coordination and determination of benefits when an individual is covered under multiple insurance plans. It helps ensure that the insurers know their respective roles and responsibilities in paying for eligible expenses.

What information must be reported on coordination of benefits form?

The information that must be reported on coordination of benefits form typically includes the policyholder's personal and insurance information, details of the primary insurance plan, details of the secondary insurance plan, and any other relevant information requested by the form.

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