August 13, 2003
Insufficient information regarding the coordination of benefits is a major source of healthcare claims processing delays. The top reasons for coordination of benefit (COB) delays include:
- Incomplete or inaccurate COB information on file with the plan or provider, and
- Failure to attach the explanation of benefits (EOB) from the primary payer when billing the secondary payer.
To decrease these most frequent omissions, the Plan-Provider Claims Workgroup has compiled some tips to help billing staff reduce COB-related claim delays.
Ask All Patients About Secondary Insurance Coverage
Have an office procedure to collect or confirm primary and secondary insurance information at each visit. Ask patients to provide the following information for themselves and for their spouses and dependents:
- Social Security number
- Birth date
- Group or policy number for other medical coverage (if applicable)
- Medicare or Medicaid ID card (if applicable)
Collect this information when the appointment is booked to allow time to confirm eligibility before the visit.
Know What Plans and Payers Need to Pay Claims
Although each plan and payer may have slightly different requirements for paying claims, there are some requirements that are nearly universal. For example, nearly all plans require a copy of the EOB from the primary payer before paying a claim as the secondary payer. Most plans and payers publish their requirements, and the information should be available in provider manuals, online, and by contacting provider representatives.
Determine Primary and Secondary Payers
It is important for providers to determine primary and secondary payers so that claims can be sent to the primary payer first. Some plans will be able to tell providers whether they are primary or secondary at the time the provider contacts the plan to verify eligibility. Typically, the following rules are used by plans and payers to determine the primary and secondary payer:
- The payer covering the patient as a subscriber will be the primary payer.
- If the patient is a dependent child, the payer whose subscriber has the earlier birthday in the calendar year will be the primary payer. This is known as the Birthday Rule.
Attach the Primary Payer EOB When Submitting Claim to a Secondary Payer
Secondary payers must have a copy of the EOB provided by the primary payer to process and pay a claim. Make attaching an EOB to claims filed with secondary payers a part of your routine office procedure.
A Special Consideration for Medicare Claims
Many health plans receive Medicare claims automatically when they are the secondary payer. In this case, the explanation of Medicare benefits (EOMB) will indicate that the claim has been automatically crossed over for secondary consideration. Providers should look for this indication on their EOMBs and should not submit a paper claim to the secondary payer. Such paper claims would be rejected as a duplicate by the secondary payer.
SOURCE:
"Coordination of Benefits: Tips for Reducing Payment Delays and Improving Accounts Receivable," prepared by HFMA and AAHP.
[insert URL]
If you have questions or comments about HFMA Wants You to Know, contact editor Laura Noble at lnoble@hfma.org.
HFMA Wants You to Know ISSN: 1540-0697. Volume II, Issue 17. Copyright 2003, Healthcare Financial Management Association. All rights reserved.