Coordination of Benefits (COB)
Provider Administrative Policy
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
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 once month prior to the expiration of current COB information.
If you are aware of other insurance information for any Blue Cross of Idaho members or other Blue Cross Blue Shield members, please supply the information to Blue Cross of Idaho on claim forms.
CMS1500 (02/12), please include the following:
- If box 11d is completed and the answer is "yes", complete box 9, 9a, and 9d.
- If box 11d is marked "yes" and box 9 fields 9, 9a and 9d are not populated, we will return the claim to the provider for information.
- If box 11d is marked "no" and box 9, 9a and 9d are populated, the claim will be returned for review and correction. You will need to remove the information within box 9 and/or correct box 11d to reflect "yes".
- If you leave box 11d blank and there is information submitted within box 9, we will return the claim to have the appropriate option selected within box 11, and/or have the information in box 9 removed.
- Enter the COB information is fields 50-62.
The COB questionnaire and online form is available on the secure provider portal of the Blue Cross of Idaho's website, 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 provided a fax transmittal form to fax with the hard copy verification insurance information.
We will reprocess 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 as 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 the 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 care - 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 claim total or by claim line)
- COB Member Liability (member liability after primary payment - by total claim or by claim line)
NOTE: BlueCard claims require additional information when submitting Medicare Other Payment Liability (OPL) values.
- Either "MB" or "MA" in the Source of Payment field as applicable. Home plans will deny BlueCard claims submitted with Medicare OPL value of "ZZ" in the Source of Payment field.
- CAS code from Medicare if billing electronically
- Group Code
- Adjustment reason code
- Dollar amount related to the CAS code identifying Medicare Sequestration
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. Please ensure you provide all primary insurance adjustment codes/remit reason codes with submitting to Blue Cross of Idaho as the secondary payer.
Primary carrier payment/remit:
|Billed||Primary Allowed||Primary Deductible||Primary Coinsurance||Primary Paid||Contractual Adjustment|
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|
Please note on the example above, we determined the secondary payment of $220.00 by adding the total of primary deductible ($100.00) and primary coinsurance ($120.00).
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 bases non-contracting provider COB reimbursements on the higher of the primary or Blue Cross of Idaho's 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 is due to the impact of the prior payer(s) adjudication.
For paper remittances, Blue Cross of Idaho will append 526, 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.
|April 2014||Revised||Added BlueCard OPL information|
|May 2013||Revised||Removed reference to the 835 Companion Guide|
|October 2011||Revised||Language revision|
|April 2010||Revised||Updated COB electronic information|
|May 2008||Revised||Language clarification|