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DPAP214

Coordination of Benefits (COB)


Provider Administrative Policy

Section
Information
Policy Date
May 2013
Status/Date
New/May 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Blue Cross of Idaho works diligently on behalf of our members to develop contracting relationships with Idaho dental providers and Blue Cross Blue Shield dental affiliates (national Dental Grid).

 


Policy

Coordination of Benefits (COB)

For Blue Cross of Idaho to apply benefits correctly, we need to know if a member has other health coverage. To help reduce the number of denied claims for coordination of benefits (COB), we send the member a letter asking for information about other insurance one month prior to the expiration of current COB information.

If you are aware of other insurance information for a Blue Cross of Idaho member, please supply the information to Blue Cross of Idaho on your claim forms. On ADA dental claim form, please include this information in item 4-11.

The COB questionnaire and online form is available on the secure provider portal on the Blue Cross of Idaho website at bcidaho.com. Select Provider, then Forms, then Coordination of Benefits Tools, and choose the printable form to complete and fax in or the online form to complete and submit electronically. We have provided a fax transmittal form to fax with the hard copy verification insurance information.

Coordination of Benefits (COB) Form

We will process any claims denied for coordination of benefit information when we receive other insurance information establishing Blue Cross of Idaho as the primary carrier. If we receive information establishing Blue Cross of Idaho is secondary, we will not reprocess claims until we receive the primary payment information. You may submit COB secondary claims electronically only if you have checked with your Practice Management software vendor to ensure they are capable of sending this information. The submission must include the following:

  • COB Type
  • COB Amount (amount paid by primary carrier-by total claim or by claim line)
  • COB Allowance (amount allowed by primary-by total claim or by claim line)
  • COB Deductible (the total amount the primary carrier applied to the member's deductible-by total claim or by claim line)
  • COB Copay (total copay applied by the primary carrier-by total claim or by claim line)
  • COB Coinsurance (total coinsurance applied by the primary carrier-by total claim or by claim line)
  • COB Member Liability (member liability after primary payment-by total claim or by claim line)

Note:  If the electronic submission is missing any of the above criteria, we may deny the claim and request a hard copy of the remittance advice from the primary insurance.

Primary carrier payment/remit:

Billed Primary Allowed Primary Deductible Primary Coinsurance Primary Paid Contractual Adjustment
$500.00 $400.00 $25.00 $75.00 $300.00 $100.00

Blue Cross of Idaho new COB legislation secondary payment/remit:

Billed Blue Cross Deductible Blue Cross Coinsurance Blue Cross Copay Non Covered Other Carrier Paid Contractual Adjustment Blue Cross Paid
$500.00 Met $0.00 $0.00 $0.00 $300.00

$100.00

$100.00

Please note on the example above, we determined the secondary payment of $100.00 by adding the total of primary deductible ($25.00) and primary coinsurance ($75.00).

When contracting providers bill Blue Cross of Idaho as a secondary payer, they are obligated to take contractual adjustments up to what they would have taken if Blue Cross of Idaho were the primary payer.

Blue Cross of Idaho will base non-contracting provider COB reimbursements on the higher of primary or Blue Cross of Idaho allowance.

For providers receiving a HIPAA electronic 835 remittance advice, Blue Cross of Idaho will append the claim adjustment reason code 23 to reflect the payment adjustment is due to the impact of the prior payer(s) adjudication. For paper remittances, Blue Cross will append 529, 209 or 8N3 based on how we received the other carrier's information.

Because of the various member and provider contract terms across different payers, it is impossible to outline every possible example. Please contact your provider relations representative if you have any questions.


Policy History

Date Action Reason