KFHPWA will generally process claims for benefits within the following timeframes after KFHPWA receives the claims: • Immediate request situations – within 1 business day. • Concurrent urgent requests – within 24 hours. • Urgent care review requests – within 48 hours. • Non-urgent preservice review requests – within 5 calendar days. • Post-service review requests – within 30 calendar days. Timeframes for pre-service and post-service claims can be extended by KFHPWA for up to an additional 15 days. Enrollee will be notified in writing of such extension prior to the expiration of the initial timeframe. X. Coordination of Benefits The coordination of benefits (COB) provision applies when a Enrollee has health care coverage under more than one plan. Plan is defined below. The order of benefit determination rules govern the order in which each plan will pay a claim for benefits. The plan that pays first is called the primary plan. The primary plan must pay benefits according to its policy terms without regard to the possibility that another plan may cover some expenses. The plan that pays after the primary plan is the secondary plan. In no event will a secondary plan be required to pay an amount in excess of its maximum benefit plus accrued savings. If the Enrollee is covered by more than one health benefit plan, and the Enrollee does not know which is the primary plan, the Enrollee or the Enrollee’s provider should contact any one of the health plans to verify which plan is primary. The health plan the Enrollee contacts is responsible for working with the other plan to determine which is primary and will let the Enrollee know within 30 calendar days. All health plans have timely claim filing requirements. If the Enrollee or the Enrollee’s provider fails to submit the Enrollee’s claim to a secondary health plan within that plan’s claim filing time limit, the plan can deny the claim. If the Enrollee experiences delays in the processing of the claim by the primary health plan, the Enrollee or the Enrollee’s provider will need to submit the claim to the secondary health plan within its claim filing time limit to prevent a denial of the claim. If the Enrollee is covered by more than one health benefit plan, the Enrollee or the Enrollee’s provider should file all the Enrollee’s claims with each plan at the same time. If Medicare is the Enrollee’s primary plan, Medicare may submit the Enrollee’s claims to the Enrollee’s secondary carrier. Definitions. A. A plan is any of the following that provides benefits or services for medical or dental care or treatment. If separate contracts are used to provide coordinated coverage for Enrollees of a Group, the separate contracts are considered parts of the same plan and there is no COB among those separate contracts. However, if COB rules do not apply to all contracts, or to all benefits in the same contract, the contract or benefit to which COB does not apply is treated as a separate plan. 1. Plan includes: group, individual or blanket disability insurance contracts and group or individual contracts issued by health care service contractors or health maintenance organizations (HMO), closed panel plans or other forms of group coverage; medical care components of long-term care contracts, such as skilled nursing care; and Medicare or any other federal governmental plan, as permitted by law. 2. Plan does not include: hospital indemnity or fixed payment coverage or other fixed indemnity or fixed payment coverage; accident only coverage; specified disease or specified accident coverage; limited benefit health coverage, as defined by state law; school accident type coverage; benefits for non- medical components of long-term care policies; automobile insurance policies required by statute to PEBB_VA_2024 65