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
When a member's primary plan is determined to be Original Medicare, Blue Cross informs Medicare of this membership. Medicare will then set up to cross over record for the member. Once set up and a claim is sent to Medicare, the claim would process as primary and cross over to Blue Cross. Blue Cross would coordinate benefits according to the member's 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 Medicare electronic remittance 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.
| Payments | 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.
| Payments | 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.