Coordination of Benefits - Which Plan Do I Bill?

It’s not uncommon for a patient to be covered by more than one health plan. Coordination of benefits (COB) is the method used by insurance companies to decide which plan will pay first in the case of additional plan coverage. Determining which plan should be billed first isn’t always easy, but knowing which payer has primary responsibility is key to avoiding delays in reimbursement.

There are several scenarios surrounding COB determination. Here are the most common:

Medicare:

While Medicare is normally the primary payer, there are instances in which they will be secondary.

· Working Aged Beneficiary Age 65 or older -the patient is covered by an employee group health plan (GHP) through their employer or their spouse’s employer that has more than 20 employees

· Disability – the patient is disabled and covered by a group health plan with more than 100 employees

· End-Stage Renal Disease – when the patient has ESRD and is covered by a group health plan, the GHP will be primary for the first 2 ½ years of Medicare eligibility. After 30 months, Medicare becomes the primary payer.

· No-fault Insurance, Liability Insurance, Workers’ Compensation – when the patient has been in an accident (vehicle accident, on-the-job injury, etc), Medicare will be secondary

Medicare Advantage Plans take the place of traditional Medicare. Medicare is not secondary to these plans.

Commercial Medical Insurance:

If a patient has dual coverage through his/her own employer and a spouse’s employer, the patient’s employer group health plan will be primary.

If a dependent child is covered under policies through both parents, most insurance companies use the “birthday rule” to determine coordination of benefits. The birthday rule states that whichever parent’s birthday comes first during the calendar year will provide primary coverage for the dependent.

Vision Insurance:

This situation is unique to the eye care industry. If a patient has routine eye exam coverage through their medical plan, the medical plan can be billed as primary for the exam and refraction. If the patient’s vision plan allows COB, providers can file a secondary claim for any remaining balance due to reduce out-of-pocket expenses to the patient.

Rules for submitting COB claims to vision plans that allow it can be located in the provider manuals on their respective websites.