Point32Health is updating our processes and procedures related to coordination of benefits (COB) claims and will be leveraging additional vendors to analyze historical claims data, in accordance with applicable policies or contracts, and perform claims payment retractions, as necessary.
Point32Health coordinates benefits when a member of one of our Harvard Pilgrim Health Care or Tufts Health Plan products has additional insurance coverage (e.g., other primary insurance, third-party liability coverage), as outlined in our handy Coordination of Benefits quick reference guide, as well as our Provider Manuals and Coordination of Benefits Payment Policy.
Per our long-standing Coordination of Benefits Payment Policy, when we determine that a member’s Harvard Pilgrim or Tufts Health Plan coverage is the secondary coverage after a claim has processed and Harvard Pilgrim or Tufts Health Plan was incorrectly identified as the primary coverage, we retract any associated claim payments. The claim must then be billed to the primary insurer and resubmitted to Harvard Pilgrim or Tufts Health Plan with the primary insurer’s explanation of benefits.
Process update and claim retractions
We will be analyzing historical claim data from our Harvard Pilgrim and Tufts Health Plan claims systems — and leveraging additional vendors for our Tufts Health Plan products — to identify instances in which we processed claims that should have been submitted to other primary payers.
As we do the work of assessing historical data and reprocessing as necessary, we will retract payments for COB claims that should not have been paid by our organization and providers will need to correctly bill the primary payer.