Coordination of benefits (COB)
COB is our process for ensuring that our members receive full benefits and helping to prevent over-payment for services when a member has coverage from two or more sources. Blue Cross follows NAIC (National Association of Insurance Commissioner) and CMS (Centers for Medicare and Medicaid Services) guidelines.
COB works, for example, when a member’s primary plan pays normal benefits and the secondary plan pays the difference between what the primary plan paid and the total allowed amount, or up to the higher allowed amount.
Medicare crossovers
We do not automatically set up claims to cross over from Medicare. When a member’s primary plan is Medicare, the member can ask to have his or her claims set up to cross over to another plan. The member must give us permission to receive this information from Medicare. The member can call the number on the back of his or her Blue Cross ID card to have claims set up to cross over or to make a change to his or her coverage information. Once set up and a claim is sent to Medicare, the claim would process as prime and cross over to Blue Cross. Blue Cross would coordinate benefits up to Medicare’s allowed amount. This includes Prepaid Medical Assistance Program (PMAP) and MinnesotaCare members when Medicare is the primary plan.
It’s always a good idea to check provider web self-service or call BLUELINE phone self-service to verify that Blue Cross has received a claim before submitting it a second time. If the EOMB indicates Medicare electronically crossed the claim to us, a re-submitted claim will be returned to the provider.
Examples of how COB works:
Example #1
Josie incurred medical expenses in the amount of $100. Both health plans considered the allowable expense to be $80 payable at 80%. Deductibles have been satisfied for both plans.
| Coordination | |
| Total charge | $100 |
| Allowed amounts by both | $80 |
| Primary paid | $64 (80% of $80) |
| Secondary paid | $16 (subtract $64 from $80) |
| Patient responsibility | $0 |
| Posting payments | Coordination |
| Total billed charge | $100 |
| Primary payment | $64 |
| Secondary payment | $16 |
| Primary reduction | $20 ($100 charge - $80 allowed) |
| Secondary reduction | Not taken, already zero balance |
| Patient responsibility | $0 |
Example #2
Thomas incurred medical expenses in the amount of $100. The primary plan allowed $80 payable at 80%. The secondary plan allowed $90 payable at 80%. Deductibles have been satisfied for both plans.
| Coordination | |
| Total charge | $100 |
| Higher allowed expense | $90 |
| Primary paid | $64 (80% of $80) |
| Secondary benefit | |
| Secondary paid | $26 (subtract $64 from $90) |
| Patient responsibility | $0 |
| Posting payments | Coordination |
| Total billed charge | $100 |
| Primary payment | $64 |
| Secondary payment | $26 |
| Primary reduction | $10 (only take $10 of the $20 reduction to get to zero balance) |
| Secondary reduction | Not taken, already at zero balance |
| Patient responsibility | $0 |
There may be some patient responsibility depending on the type of coordination the member’s plan requires.