Coordination of Benefits (COB)

Coordination of benefits (COB) is a reason why claims are “Denied.”

Coordination of Benefits (COB) is when a patient has more than one healthcare insurance company. The patient needs to call each insurance company to coordinate the benefits, i.e. which is primary or secondary. This a big reason for claims to be Denied or Take-backs from insurance. Insurance may also deny claims until the patient calls to confirm they have no other healthcare insurance. For the official overview, see the CMS Coordination of Benefits & Recovery page.

Insurance will “deny” claims for coordination of benefits (COB)

How is Fixed?

• The provider or a representative from the office cannot solve this issue.
• Only the patient can solve this issue by calling the insurance company or “Member Services” on the back of the insurance card

When the patient has multiple healthcare insurances

• The patient must call the “Member Services” on the back of the insurance card for each insurance company
• In the call they are to inform the insurance company if they have any other “active” healthcare insurances
• If so, they must declare which one they wish to to primary and secondary
• Then the patient must call the second healthcare insurance to declare all insurances, along with declaring which is primary and secondary
• Have the patient notify the provider and the office to when the calls were placed to insurance, so that, you may follow-up on the claims to have them processed by the insurance
• The providers office, must confirm that they have the member ID information for all insurances. Ideally, the provider will have a copy of the insurance card for all insurances.
• After the primary claim has processed, the secondary claim may be submitted with proof of the adjudication of the primary claim(s)
• See video on submitting secondary claims to insurance

How to tell a COB denial from other denials

A COB denial usually points to other coverage on file. Check the remittance advice for the denial reason and remark codes, then compare them with the eligibility response from the payer. If the payer lists another plan as primary, the claim was sent to the wrong payer first or the payer record is out of date.

What the billing office can do

• Verify eligibility and ask about other coverage at every intake and again at the start of each year.
• Record the primary and secondary payers, the policy holder and the effective dates in the client chart.
• Bill the primary payer first. Send the secondary claim with the primary payer’s remittance after the primary pays.
• Ask the client to call Member Services when the payer is waiting on a coverage update. Only the member can clear that flag.
• Track the claim and resubmit as soon as the payer confirms the update.

COB and out-of-network claims

Payer rules for primary and secondary order differ between plans, and the same rules apply whether a provider is in network or out of network. To see how network status changes what a payer pays, read in-network vs out-of-network credentialing. For help with secondary claims and denied claims, see MCM South billing services for psychotherapists and psychiatrists.

Questions to ask the payer

Which plan do you list as primary? What date did the other coverage start? What does the claim need to be paid after the update? Write down the call reference number and the date of the call.