Managed Care - INFO

We are the largest on-line , managed care and insurance information web site in the world !

Coordination of Benefits is a system that determines which health plan or payer, pays for services first when a patient is covered by more than one health plan. The definition is a provision in a contract that applies to a person who is covered by more than one medical plan. This may occur when a person is covered under their spouse's health plan. It requires that payment of benefits be coordinated by all programs, to eliminate over insurance or duplication of benefits.

All health plans or payers will actively pursue a COB program with other insurance carriers. By doing this, the health plan can determine which plan will pay for a claim first, before the other plan pays. Being first in insurance terms means that the carrier will be called the "Primary" payer. The other carrier will be classified as "Secondary".

All individuals who are members of a healthplan, usually are required to participate in the COB program. Many healthplans determine who is Primary by using the following procedure:

1. If one of the healthplans has a COB program in its contract and the other does not, the carrier without the COB clause will have Primary responsibility.

2. If both carriers have a COB program, the carrier covering the patient as a subscriber will have the Primary responsibility.

3. If both carriers have a COB program, and both carriers cover the subscriber as a dependent, the carrier whose subscriber has the earlier birthday in the calendar year will have the Primary responsibility. This is known as the Birthday Rule.

4. If both carriers have a COB program, and neither 1,2,3 above apply to the subscriber, the carrier who has covered the subscriber longer in their program will have the Primary responsibility.

Medicare Coordination of Benefits

The Coordination of Benefits (COB) Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purposes of the COB program are to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits. The COB Contractor does not process claims, nor does it handle any mistaken payment recoveries or claims specific inquiries. The Medicare intermediaries and carriers are responsible for processing claims submitted for primary or secondary payment. To resolve your questions regarding whom to contact, see below:

 Contact the COB Contractor to:

• Report employment changes, or any other insurance coverage information.
• Report a liability, auto/no-fault, or workers compensation case.
• Ask general Medicare Secondary Payer (MSP) questions/ concerns.
• Ask questions regarding Medicare Secondary Development (MSP) letters and questionnaires.

 Contact your local Medicare intermediary or carrier to:

• Answer your questions regarding Medicare claim or service denials and adjustments.
• Answer your questions concerning how to bill for payment.
• Process claims for primary or secondary payment.
• Accept the return of inappropriate Medicare payment.

 Contact 1-800-MEDICARE (1-800-633-4227) to:

• Obtain general Medicare information.
• Obtain information about Medicare Health Plan choices.
• Order Medicare publications.

 Contact SSA to:

• Enroll in the Medicare program.
• Replace your Medicare card.
• Change your address.
• Verify Medicare coverage.