coordination of benefits (cob) documentation...• calculation 2: subtract the cob paid amount from...
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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
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COB Introduction by Claim Type
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COB Introduction by Reimbursement Method
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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
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Submitting Claims
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Submitting Claims
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Submitting Claims
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Rosters
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COB Information on the Claim Form
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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
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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.
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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.
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COB PricingCalculations
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“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
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“Member Responsibility” Examples
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“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
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“Lesser of” Examples
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“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.
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“Medicaid Allowed Amount Minus Primary Insurance Payment” Examples
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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”
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Adding Attachments
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Adding Attachments
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Adding Attachments
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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.
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Adding Attachments
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Provider Relations Consultants
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Region 1 and the state of Washington
(208)373-1309 Region.1@DXC.Com
Region 2 and the state of Montana
(208)373-1326 Region.2@DXC.Com
Region 3 and the state of Oregon
(208)373-1475 Region.3@DXC.Com
Region 4 and all other states
(208)373-1351 Region.4@DXC.Com
Region 5 and the state of Nevada
(208)373-1357 Region.5@DXC.Com
Region 6 and the state of Utah
(208)373-1325 Region.6@DXC.Com
Region 7 and the state of Wyoming
(208)373-1408 Region.7@DXC.Com
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.
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