Certified Revenue Cycle Representative (CRCR) Practice Exam

Self-funded benefit plans may choose to coordinate benefits using which rule along with the gender rule?

1. Birthday

2. Eligibility

3. Age

4. Income

The correct answer is: Birthday

Self-funded benefit plans often utilize the birthday rule along with the gender rule for coordinating benefits. The birthday rule stipulates that when a child is covered by more than one health plan, the plan of the parent whose birthday falls earliest in the calendar year pays first. This approach is designed to provide a clear and straightforward method for determining primary coverage when multiple insurance plans are in play. In this context, the birthday rule complements the gender rule, which may prioritize coverage based on the parent’s gender under certain plan provisions. Utilizing the birthday rule helps to avoid potential disputes between insurers regarding which plan should be the primary one, ensuring that processing claims is more efficient and fair based on a standardized criterion. The other options do not align with the typical coordination of benefits practices for self-funded plans. The eligibility rule is more about whether an individual qualifies for benefits rather than how benefits are coordinated between plans. The age rule might refer to varying levels of coverage based on a member's age, but it is not a common method for determining primary coverage. The income rule does not relate to coordination of benefits; instead, it pertains to financial eligibility for certain programs or assistance. Thus, the birthday rule stands out as the correct choice in this scenario.