Coordination of Benefits (COB) | SSM Health (2024)

FAQs

How do you complete the coordination of benefits? ›

To set up coordination of benefits, you will need to contact your insurance company. Your insurance company will ask you to fill out a form disclosing any other health plans you may have in place. To gather this information your insurance company may: send you a form in the mail.

For example, suppose you visit your doctor and get billed $250 for the appointment. Your primary health plan may cover the majority of the bill. Let's say, for example, that's $200. Then your secondary plan would pay the remaining $50.

Calculation 1: Add together the primary's coinsurance, copay, and deductible (member responsibility). If no coinsurance, copay, and/or deductible, payment is zero. Calculation 2: Subtract the COB paid amount from the Medicaid allowed amount. When the Medicaid allowed amount is less than COB paid, the payment is zero.

Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.

The accompanying coordination of benefits (COB) questionnaire contains questions about other forms of insurance you may have. Having up-to-date COB information enables your employer's benefit plan to save money by avoiding duplicate payments or overpayment.

Coordination of benefits allows two insurance carriers to determine their fair share of the cost for covered services. Your out-of-pocket cost for services is limited to the amount, if any, that remains unpaid by the insurers.

Two COB Methodologies

One method is known as the “non-duplication” (or “non-dup”) method. The other method is known as the “come out whole” method.

Explanation: A key step when handling coordination of benefits for a patient is to bill the patient's insurance plans in the proper order. This process involves determining the primary and secondary insurance providers and ensuring that the primary plan pays first before the secondary plan is billed.

About Coordination of Benefits

COB claims are those sent to secondary payers with claims adjudication information included from a prior or primary payer (the health plan or payer obligated to pay a claim first). These claims can be sent 1) from provider to payer to payer or 2) from provider to payer.

Longer/Shorter Length of Coverage.

If none of the above rules determines the order of benefits, the benefits of the plan that covered an employee or Member longer are determined before those of the plan that covered that person for the shorter term.

What is the difference between COB and EOB insurance? ›

The EOB, which you receive from an insurance provider after submitting a claim, will play an integral part in obtaining a COB. Sending out an EOB to another insurance is how you can receive your EOB. COB refers to the process of determining which insurance carriers will cover which portion of fiscal responsibility.

What is an example of coordination of benefits? If a divorced couple with a 10-year-old child has to pay for a medical procedure, then the custodial parent's insurance will pay first. The noncustodial parent's health insurance will cover any leftover costs up to the policy's limits or the bill's full cost.

COB denials typically occur when multiple insurance plans are involved in covering a patient's healthcare costs, and there is confusion or lack of clarity about which plan is primary and which is secondary.

Final answer: The false statement about COB is "D. It coordinates payments for services up to 50 percent of the covered charges." COB ensures that the total payments do not exceed 100% of the covered charges by working out the payment responsibilities between multiple health insurance plans.

If you have coverage under a plan from your employer in addition to a spouse's or parent's plan, your own plan will be primary and the other plan will be secondary. This is also true if the additional coverage is with TRICARE or Medicaid, as those plans are always the secondary insurer if you have other coverage.

Call the Benefits Coordination & Recovery Center at 1-855-798-2627. TTY users can call 1-855-797-2627. Contact your employer or union benefits administrator. Also, tell your doctor and other health care providers about your health or drug coverage changes the next time you get care.