58-18A-66. Order of benefit payments.
397 words·~2 min read·
/sd/title-58/chapter-58-18/58-18a-66·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
If a person is covered by two or more plans, the provisions for determining the order of benefit payments are as follows:
(1)The primary plan shall pay or provide its benefits as if any secondary plan did not exist;
(2)If the primary plan is a closed panel plan and the secondary plan is not a closed panel plan, the secondary plan shall pay or provide benefits as if it were the primary plan when a covered person uses a nonpanel provider, except for emergency services or authorized referrals that are paid or provided by the primary plan;
(3)If multiple contracts providing coordinated coverage are treated as a single plan under §§ 58-18A-53 to 58-18A-83 , inclusive, this section applies only to the plan as a whole, and coordination among the component contracts is governed by the terms of the contracts. If more than one carrier pays or provides benefits under the plan, the carrier designated as primary within the plan shall be responsible for the plan's compliance with §§ 58-18A-53 to 58-18A-83 , inclusive;
(4)If a person is covered by more than one secondary plan, the order of benefit determination provisions of §§ 58-18A-53 to 58-18A-83 , inclusive, decide the order in which secondary plans benefits are determined in relation to each other. Each secondary plan shall take into consideration the benefits of any primary plan and the benefits of any other plan, which, under the provisions of §§ 58-18A-53 to 58-18A-83 , inclusive, has its benefits determined before those of that secondary plan;
(5)Except as provided in subdivision
(2)of this section, a plan that does not contain order of benefit determination provisions that are consistent with §§ 58-18A-53 to 58-18A-83 , inclusive, is always the primary plan unless the provisions of both plans, regardless of the provisions of this section, state that the complying plan is primary;
(6)Coverage that is obtained by virtue of membership in a group and designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the contract holder. Examples of these types of situations are major medical coverages that are superimposed over base plan hospital and surgical benefits, and insurance type coverages that are written in connection with a closed panel plan to provide out-of-network benefits.