COB & TPL Words to Know

3. A claim for a member who is enrolled in both Medicare and Medicaid, where Medicare, as the primary payor, has made a payment or has approved an amount to be paid and then forwards the claim to Medicaid for payment of the member's coinsurance and deductible.
5. Personal Injury Protection
6. Insurer responsible for paying first on any medical claim.
8. Rules that establish the order in which health insurers pay claims when more than one insurer provides coverage for a member.
9. Lien filed by an insurer, in accordance with Law to protect its right to reimbursement and/or recovery after one of its members is injured due to third-party negligence.
12. Detailed explanation of an insurer’s payment or denial of a claim sent to a member;(EOB).
14. Federal and state mandate that state providers must bill all of a member’s other insurers before submitting a claim to Tufts Health Plan.
15. Other health insurance carriers are Medicare, TriCare, commercial group plans, HMOs other governmental benefits.

1. Insurance that provides compensation for medical expenses incurred by an individual injured in the course of employment.
2. Insurer responsible for paying second on any medical claim.
4. Detailed explanation of an insurer’s payment or denial of a claim sent to a provider;(EOP).
7. Auto insurance that covers medical and funeral expenses resulting from an accident involving a policyholder and any passengers riding with the policyholder.
10. A claim against an asset for payment due to payor when funds become available; secures right to recovery for payor.
11. Refers to the claims that are denied for payment by the secondary payor due to the existence of other insurance determined to be a primary payor.
13. A situation in which Members have additional coverage that pays for their care medical expenses, usually after an accident (e.g., auto accident, accidental injury, slip and fall, dog bites, product liability, medical malpractice, restitution cases).