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Coordination of Benefits - Group Health and Dental

Release Date: 09/12/2012
Staff Reference: Sheila Burns

Guideline G4

The CLHIA has developed this Guideline for the health and dental benefits industry to help promote consistency in determining the priority in which payments are made and to outline the minimum amount payable by each Group Plan in situations where a Covered Individual can submit a claim to more than one Group Plan. This Guideline describes the order in which benefits are determined and how to coordinate health or dental payments from Group Plans available to the Covered Individual.

The combined payment from all Group Plans for a particular item cannot exceed 100% of the Eligible Medical Expense or Eligible Dental Expense. In some cases, the combined payment from all Group Plans on a particular item may be less than the submitted amount.