Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingMedium
A patient covered under two employer group health plans (one through her own job, one through her spouse's job) needs coordination of benefits determined for her child's claim. Both parents carry the child as a dependent. Which rule determines which plan pays first?
- AThe plan with the higher monthly premium pays first
- BThe plan of the parent whose birthday falls earlier in the calendar year pays first
- CThe mother's plan always pays first regardless of birthdate
- DThe plan of the parent who has been employed longer pays first
Show answer & explanationAnswer & explanation
Correct answer: B. The plan of the parent whose birthday falls earlier in the calendar year pays first
The 'birthday rule' is the standard coordination-of-benefits guideline: when a dependent child is covered by both parents' group plans, the plan of the parent whose birthday (month and day, not year) falls earlier in the calendar year is the primary payer.
Why the other options are wrong
- A. Premium amount does not determine primary payer status.
- C. Gender of the parent is not a factor under the birthday rule.
- D. Length of employment is not a recognized COB standard.
Birthday Rule (COB)
A coordination-of-benefits guideline stating that when a dependent child is covered by two parents' group health plans, the plan of the parent whose birthday occurs earlier in the calendar year is primary.
- Uses month/day only, not birth year
- Applies to dependent children covered under both parents' plans
- Prevents duplicate full payment by both insurers
Memory trick: Earlier birthday = earlier payer