coordination of benefits (cob) documentation...• calculation 2: subtract the cob paid amount from...

Coordination of Benefits (COB)

Idaho Department of Health & Welfare

Overview

• COB by Claim Type and Reimbursement Methods

• Completing COB on the portal

• COB pricing calculations

Idaho Department of Health & Welfare 2

COB Introduction by Claim Type


COB Introduction by Reimbursement Method


Entering COB Information

Regardless of how you submit your claims, you can complete the COB information through your Trading Partner Account (TPA)

• Claims in OPEN, ADJUDICATE, or PEND status can have COB information updated

• It is not recommended to alter claims when in a PAY or DENY status

• We do not recommend that you adjudicate secondary claims

Note: Remember to turn off pop-up blockers


Submitting Claims


Rosters


COB Information on the Claim Form


COB Information

• You will need to select Commercial or Medicare in the filing indicator

• Enter the payer name and sequence, the policy number is optional

• Click the enter COB Details to enter the primary payer details• It is best to enter by service line• All fields, except policy number and adjustment reason are

required for processing. • Select submit to go back to claim


COB Information

• The Coordination of Benefits (COB) calculation is performed at the claim level for all claims

• Calculation is not performed line by line, however it is best to report at line level for reporting and auditing purposes

• Amounts entered at the claim detail level are summed up for the claim and then the COB calculation is performed

• Payment is then distributed to the claim detail lines

Note: It is necessary to report the Other Insurance/ Medicare Advantage or Medicare paid amount, deductible amount, coinsurance, and copayment amounts for correct payment consideration. The allowed amount is calculated based on the amounts provided.


Balance Billing

Balance billing of coinsurance, copay, and/or deductible is not allowed.

As a reminder: once primary has processed and Medicaid has processed, the remaining balance cannot be billed to the participant.


COB PricingCalculations


“Member Responsibility”

The primary’s coinsurance, copay, and deductible.

Calculation: Add coinsurance, copay, and deductible.

If no Member Responsibility is reported, the payment is zero.

Claims paid with this method: Hospital inpatient, Medicare Part A, QMB-Only members


“Member Responsibility” Examples


“Lesser of”

The lesser of the primary member’s responsibility, OR Medicaid allowed amount minus the primary’s payment.

• Calculation 1: Add together the primary’s coinsurance, copay, and deductible (member responsibility). If no coinsurance, copay, and/or deductible, payment is zero.

• Calculation 2: Subtract the COB paid amount from the Medicaid allowed amount. When the Medicaid allowed amount is less than COB paid, the payment is zero.

Claims paid with this method: Medicare Part B, outpatient, and professional services claims


“Lesser of” Examples


“Medicaid Allowed Amount Minus Primary Insurance Payment”The primary’s payment is subtracted from the Medicaid allowed amount.

Calculation: Medicaid contract amount minus COB paid amount.

Claims paid with this method: Long Term Care, RHC, FQHC, and IHC.


“Medicaid Allowed Amount Minus Primary Insurance Payment” Examples


Medicare Covered/Non-Covered

• Claims submitted with both Medicare covered and Medicare non-covered services on the same claim will be denied as they require split billing

• If modifier GY, GZ, GO, GN, or GP is reported on Medicare non-covered services, services are allowed to be billed together

• Claim Status on the portal will show edit 6215 on denied claims when both Medicare covered and non-covered services are submitted

• Remit message N61 will appear on Remittance advise, indicating “Re-bill services on separate claims”


Adding Attachments


Adding Attachments

Make sure to choose Medical from the drop-down as the type of attachment.

Note: When submitting a new day claim, the attachment option will be available after submission.


Adding Attachments


Provider Relations Consultants


Region 1 and the state of Washington

(208)373-1309 [email protected]

Region 2 and the state of Montana


Region 3 and the state of Oregon


Region 4 and all other states


Region 5 and the state of Nevada


Region 6 and the state of Utah


Region 7 and the state of Wyoming


mailto:[email protected]







Thank you for attending our Coordination of Benefits

Training.

Please take a few minutes to complete the survey that will be emailed following this

presentation. This provides us with valuable information for future trainings.


coordination of benefits (cob) documentation...• calculation 2: subtract the cob paid amount from...

Documents