coordination of benefits (COB)

Coordination of Benefits

Other health insurance coverage information is important in the coordination of benefits (COB) process.

COB occurs when a member is covered by two or more insurance plans.

You can assist in the COB process by asking your Blue Cross patients if they have other coverage and indicating this information in Block 9 on the CMS-1500 claim form.

When COB is involved, claims should be filed with the primary insurance carrier first. When an Explanation of Benefits (EOB) is received from the primary carrier, the claim then should be filed with the secondary carrier, attaching the primary carrier EOB.

If claims are filed with the primary and secondary insurance carrier at the same time and Blue Cross is the secondary carrier, claims will be pending for applicable other coverage information from the member. If the requested information cannot be obtained from the primary carrier’s explanation of benefits or the member has not provided a response to our other coverage questionnaire, the claim will be rejected within 21 days. Once a rejection appears on the Payment Register/Remittance Advice, the patient may be billed for the total charge.

Medicare Primary Coordination of Benefits

Blue Cross coordinates with Medicare like we do with any other carrier that is the primary carrier for OGB members.

Coordination of Benefits Questionnaire

To streamline claims processing and reduce the number of denials, a COB questionnaire is available to you online at >Forms for Providers. When treating Blue Cross members and you are aware that they might have other health insurance coverage such as Medicare, give them a copy of the questionnaire during their visit. Ask them to complete the form as soon as possible and send it to the Blue Plan through which they are covered. Members will find the appropriate contact information on their ID card.

Any services provided to a Horizon NJ Health member is reviewed against benefits provided for
that same individual under other insurance carriers with whom the member has coverage.
Horizon NJ Health, as a managed care program for Medicaid and New Jersey FamilyCare
members in New Jersey, is the “payor of last resort” on claims for services provided to members
also covered by Medicare, employee health plans or other third party medical insurance. Payors
which are primary to Horizon NJ Health include (but are not limited to):

• Private health insurance including assignable indemnity contracts
• Health Maintenance Organizations (HMOs)
• Public health programs such as Medicare
• Profit and non-profit health plans
• Self insured plans
• No-fault automobile medical insurance
• Liability insurance
• Worker’s compensation
• Other liable third parties

In cases where another insurer, other than Medicare, is deemed responsible for payment, Horizon NJ Health will pay the difference between our maximum allowable expense and the amount paid by the primary insurer provided this amount does not exceed the lowest contractually agreed amount and does not exceed the normal Horizon NJ Health benefits which would have been payable had no other insurance existed. When you provide services to a member who has any other coverage, bill the member’s primary insurer directly. Make sure that you follow that insurer’s standard claim submission policies and forms.

Upon receipt of payment, submit applicable claims to Horizon NJ Health for payment of  deductibles and coinsurance amounts. Horizon NJ Health reimburses after coordination of benefits and only up to the primary contracted rate for the service. The claim, PCP referral and the primary insurer’s Explanation of Benefits (EOBs) must be submitted within 60 days of the date of the EOB or within 180 days of the dates of service, whichever is later.

When preparing the claim, include a complete record of the original charges and primary (or additional) payor’s payment as well as the amount due from the secondary or subsequent payor. Submit all pages of the primary (or additional) insurer’s EOB to avoid delays in completing claims due to missing information or coding and message descriptions. This information ensures accurate coordination of benefits.

With the exception of Medicare, Horizon NJ Health’s same notification policies that are routinely applied and required must be followed for any claims to be considered for payment.

IMPORTANT – All Coordination of Benefit (COB) claims must be submitted with a copy of the EOB from the primary insurer.

Medicare coordination of benefits
coordination of benefits denial


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