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PAP701

Federal Employee Plan® Coordination of Benefits (COB)


Provider Administrative Policy

Section
FEP
Policy Date
August 2005
Status/Date
Revised/July 2012
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.

Policy

Federal Employee Plan® Coordination of Benefits (COB)

When an individual has coverage from both Blue Cross of Idaho FEP® and another plan, Blue Cross of Idaho will coordinate benefits with the other insurer. The primary plan has the first responsibility for claims payment and will process according to the plan benefits. The secondary plan will make up the difference between the primary plan's benefit payment and the secondary plan's covered charges. Subject to our applicable deductible (standard option) and coinsurance or copayment amounts. Reimbursement equals up to 100 percent of the covered charges, but the combined payments may or may not equal the entire amount billed by the provider.

When Blue Cross of Idaho FEP® is the primary payer:

  • Blue Cross of Idaho pays the benefits as described in the FEP® Service Benefit Plan Brochure as if the other carrier did not provide benefits.

When Blue Cross of Idaho FEP® is the secondary payer:

  • We will determine benefits after the primary plan has paid, and may reduce our reimbursement as a result.
  • All preferred and participating providers are required to accept the local plan's PPO/PAR allowance as payment in full.
  • Providers may not balance bill the enrollee.
  • The amount paid by both plans shall not exceed the amount Blue Cross of Idaho FEP® would have paid had it been primary.

You may submit COB secondary claims electronically only if you have verified with your practice management software vendor to ensure they are capable of sending this information. You must include the following with your submission:

  • COB type
  • COB amount (amount paid by primary carrier - by total claim or by claim line)
  • COB allowance (amount allowed by primary carrier - 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 copayment (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:  If the electronic submission is missing any of the above criteria, the claim may be denied requesting a hard copy of the remittance advice from the primary insurance. 

Please refer to the 835 companion guide for correct loops and segments.

OBRA guidelines regulate reimbursement for services provided to enrollees and covered family members who are entitled to benefits from both FEP® and Medicare.


Policy History

Date Action Reason
July 2012 Revised Added registration mark
April 2010 Revised Updated COB electronic information
March 2009 Revised Second sentence revised

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