Friday, 30 September 2016

Insurance CO-ordination benefits

Coordination of Benefits

Other health insurance coverage information is important in the coordination of benefits (COB) process.

COB occurs when a member is covered by two or more insurance plans.

You can assist in the COB process by asking your Blue Cross patients if they have other coverage and indicating this information in Block 9 on the CMS-1500 claim form.

When COB is involved, claims should be filed with the primary insurance carrier first. When an Explanation of Benefits (EOB) is received from the primary carrier, the claim then should be filed with the secondary carrier, attaching the primary carrier EOB.

If claims are filed with the primary and secondary insurance carrier at the same time and Blue Cross is the secondary carrier, claims will be pending for applicable other coverage information from the member. If the requested information cannot be obtained from the primary carrier’s explanation of benefits or the member has not provided a response to our other coverage questionnaire, the claim will be rejected within 21 days. Once a rejection appears on the Payment Register/Remittance Advice, the patient may be billed for the total charge.

Medicare Primary Coordination of Benefits

Blue Cross coordinates with Medicare like we do with any other carrier that is the primary carrier for OGB members.

Coordination of Benefits Questionnaire

To streamline claims processing and reduce the number of denials, a COB questionnaire is available to you online at >Forms for Providers. When treating Blue Cross members and you are aware that they might have other health insurance coverage such as Medicare, give them a copy of the questionnaire during their visit. Ask them to complete the form as soon as possible and send it to the Blue Plan through which they are covered. Members will find the appropriate contact information on their ID card.


Subrogation is a contract provision that allows healthcare insurers to recover all or a portion of claims payments if the member is entitled to recover such amounts from a third party. The third party’s liability insurance carrier normally makes these payments. A third party is another carrier, person or company that is legally liable for payment from the treatment of the claimant’s illness or injury. All claims you submit to Blue Cross must indicate if work-related injuries or illnesses are involved and if the services are related to an accident.

Providers should:

• Not require the Blue Cross member or the member’s attorney to guarantee payment of the entire billed charge.
• Not require the Blue Cross member to pay the entire billed charge up front.
• Not bill the Blue Cross member for amounts above the reimbursement amount/allowable charge.
• Charge the member no more than is ordinarily charged other patients for the same or similar service.
• Bill the member only for any applicable deductible, coinsurance, co-pay and/or noncovered service.
If amounts in excess of the reimbursement amount/allowable charge were collected, you should refund that amount to the member.

In the case of OGB claims, Blue Cross pursues recovery of claims payments and Blue Cross makes payments as applicable.

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