bcbs coordination of benefits Process and Models

The BCBS coordination of benefits process is designed to prevent overpayment and ensure that patients receive the care they need without financial burden. This process involves determining which plan is primary and which is secondary, and then allocating payments accordingly.

Primary and secondary plans are determined based on the plan's contract with the patient, and the order of payment is typically determined by the plan's contract with the patient. In some cases, the patient may have multiple secondary plans, which are then paid in a specific order.

The BCBS coordination of benefits process uses various models to determine payment, including the "first payer" model and the "pro-rata" model. The "first payer" model pays the primary plan first, while the "pro-rata" model divides the payment between the primary and secondary plans based on their contract with the patient.

Understanding the BCBS coordination of benefits process and models can help patients navigate the healthcare system and avoid unexpected medical bills.

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Coordination of Benefits (COB) is a process that determines which health insurance plan should pay for covered services first. This process ensures that no one collects more than the actual cost of the covered health expenses.

If a person has coverage under more than one Health Benefit Plan, COB applies. For instance, Arkansas Blue Cross and Blue Shield may coordinate benefits between the health insurances covering the individual.

COB is the process of determining which of a member's benefit plans should assume primary, secondary, and tertiary financial responsibility for health care services. The goal is to ensure that patients receive up to 100% of the cost of covered services.

One plan is determined to be primary and its benefits are applied to the claim first. Reimbursement of the remaining balance is considered through the secondary policy, subject to benefit provisions. Payment sources include Highmark plans as well as other commercial health care plans, automobile/liability insurers, and government programs such as Workers' Compensation and Medicare.

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To complete the COB process, providers must bill the primary payer first. The primary payer then pays their share of the claim, and the secondary payer pays their share. This process is outlined in the example below:

In this example, the primary payer pays $400.00, and the secondary payer pays $100.00. The member's liability is $100.00.

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When determining who the primary insurer is, it's essential to consider the specific circumstances of each individual or family. This can affect how claims are processed and what costs are covered.

The primary insurer is typically the plan that would cover the services first. For members with both dental and medical coverage through the same provider, the medical plan is considered primary, except for FEP members.

In cases where each spouse has their own active employer group plan, each spouse is primary on their own plan and secondary on their spouse's plan, assuming no Medicare is involved.

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If the parents are married or living together, the plan of the parent whose birthday falls first in the calendar year is primary. If the parents are not married or living together, the plan of the parent with custody is primary, with the spouse of the parent with custody as secondary and the non-custodial parent as tertiary.

Here's a breakdown of the primary insurer in different family situations:

Keep in mind that these provisions apply in the absence of a specific court decree assigning responsibility for the child's healthcare expenses to a particular parent.

If you're a parent with health insurance, you're probably wondering how to determine which plan is primary for your dependent children. The birthday rule is used to determine which plan pays first, with the plan of the parent whose birthday falls earlier in the year being primary.

The birthday rule applies to married parents, parents living together, and parents with joint custody. If the parents are separated or divorced, the plan of the parent with whom the child lives pays first, followed by the plan of the stepparent, and then the plan of the parent without custody.

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Here are the rules for determining primary coverage for dependent children:

In some cases, a court order can establish a different order, so it's essential to check your membership file or contact your insurance provider to confirm the primary plan.

If you have other health insurance, you need to provide the information to your primary insurance provider to ensure accurate coordination of benefits.

To do this, you can fill out the Other Insurance/Coordination of Benefits form or contact your insurance company directly. For example, Arkansas Blue Cross and Blue Shield requires you to mail the completed form to their Claims Division at Post Office Box 2181 in Little Rock, Arkansas 72203.

You can also contact Blue Cross of Idaho to supply the information on your claim forms, specifically in item 4-11. This will help reduce the number of denied claims for coordination of benefits.

To complete the online form and submit it electronically, you can follow the steps outlined by Blue Cross of Idaho, which include hovering over Tools & Reports, selecting Coordination of Benefits, and launching the online form.

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If you have multiple health plans covering your dependent children, the primary plan is determined by the birthday rule or the gender rule.

The birthday rule applies when both parents provide coverage for their dependent children. In this case, the plan of the parent whose date of birth (month and day) arrives earlier in the calendar year is the plan that pays first.

The birthday rule applies only in specific situations: when the parents are married, living together and not married to anyone else, or when there is a court order for joint custody with no assigned financial responsibility.

If the parents are separated or divorced, the plan of the parent with whom the child lives pays first, followed by the plan of the stepparent with whom the child lives, and then the plan of the parent without custody.

Here's a summary of the rules for determining the primary plan for dependent children:

Remember, these rules may vary depending on your specific situation and the policies of your health plans.

Medicare is Secondary Payer for the Working Aged, but only when an employer group health plan has 20 or more full-time and/or part-time employees. This applies to single employers or multiple employers who sponsor or contribute to the employee group health plan.

Under the TEFRA law, the employee group health plan is the primary payer, and Medicare is the secondary payer. To determine if TEFRA applies, you can use Message this Payer in Availity.

The Centers for Medicare & Medicaid Services (CMS) has a consolidated claim crossover process, eliminating the need to separately bill the secondary payer. This is done through the Coordination of Benefits Agreement, which automatically forwards Medicare claims to the secondary payer.

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Highmark as a secondary payer is a crucial concept to understand, especially when dealing with Medicare and other insurance providers. Highmark is considered secondary in certain situations.

Highmark's secondary status means that another insurance provider, such as automobile insurance, workers' compensation, or liability insurance, will be the primary payer in the event of an accident or injury. This is the case for injuries received in an automobile accident, work-related illnesses or injuries, or when another party is deemed responsible.

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Highmark's role as a secondary payer is to coordinate benefits and apply their group benefits, such as co-payments, coinsurance, and deductibles, to any remaining balances after the primary payer has made their payment. This is in line with the Regular Medicare COB Model, which ensures that Highmark will coordinate benefits up to the Medicare allowance.

Here are the situations where Highmark is considered secondary:

It's essential to note that Highmark's secondary status does not necessarily mean they will pay less than the primary payer. In some cases, they may pay the same amount as the primary payer, especially if the primary payer has paid more than or equal to Highmark's original payment. This is in line with the Hard Non-Duplication COB Model, which ensures that Highmark will never pay more than they would have paid as the primary payer.

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Medicare is the secondary payer for working-aged employees in employer group health plans with 20 or more full-time and/or part-time employees. This is due to the TEFRA law and subsequent legislation.

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The employee group health plan is the primary payer in these cases. To determine if TEFRA applies, you can open a claim inquiry using Message this Payer in Availity.

If TEFRA does apply, Medicare will pay secondary to the primary payer. This is important to know when processing claims.

Medicare uses several COB payment methodologies when not the primary payer. These include the NAIC Model, Regular COB, Hard non-duplication, Soft non-duplication I, Soft non-duplication II, Regular Medicare COB, and Customized COB.

Here are some of the COB payment methodologies used by Medicare when not the primary payer:

In Pennsylvania and West Virginia, Medicare crossover is a streamlined process that saves time and reduces administrative costs. This process is managed by the Centers for Medicare & Medicaid Services (CMS) through a special Coordination of Benefits Contractor (COBC). The COBC automatically forwards Medicare claims to the secondary payer, eliminating the need to separately bill the secondary payer.

Medicare crossover eliminates the need to submit separate claims and copies of Explanation of Medicare Benefits (EOMB) statements to the secondary payer. Sending unnecessary paper claims and EOMB statements can cost money and slow down all claims processing, so it's best to avoid this practice.

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Highmark uses the NAIC Model COB Regulation, which is the most common methodology used for calculating secondary payments in COB situations.

This model applies to all commercial group products and is a common industry standard supported by the Blue Cross Blue Shield Association.

There are also two Soft Non-Duplication COB models, Soft Non-Duplication I and Soft Non-Duplication II, which determine the amount Highmark would have paid as primary and never pay more than that amount as secondary.

In the Soft Non-Duplication I model, Highmark applies their group benefits, such as co-payments, coinsurance, and deductibles, to any balances after the coordination of benefit methodology is applied.

With the Soft Non-Duplication II model, Highmark pays the lesser of the two amounts, not to exceed the primary Other Insurance member liability, and then pays the Other Insurance member liability at 100% reimbursement after any copayments are applied.

The Hard Non-Duplication COB model is also used, where Highmark first determines the amount it would have paid as primary, and as a secondary payer, Highmark will never pay more than it would have paid as primary.

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The Hard Non-Duplication Model is a method used for coordination of benefits. This model ensures that patients receive up to 100% of the cost of covered services without overpaying.

In this model, the primary payer determines the amount it would have paid if it were the secondary payer. If the primary payer has paid more than or equal to the original payment, no additional payment will be made. The primary payer's payment is deducted from the original payment, and the lesser of the two amounts is paid at 100% reimbursement.

With the Hard Non-Duplication Model, the member always receives credit for the original deductible and coinsurance expenses. This model is applied when Medicare is primary, and the calculations remain the same as in the Hard Non-Duplication definition.

The formula for this model is as follows:

Here is a table illustrating the Hard Non-Duplication Model:

In this example, the primary payer's payment of $100 is deducted from the original payment of $150, resulting in a reimbursement of $50. If the primary payer's payment is $200, no additional payment is made, and the reimbursement is $0.

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The Soft Non-Duplication Model is a key part of the Coordination of Benefits process.

Highmark uses two different Soft Non-Duplication Models: Soft Non-Duplication I and Soft Non-Duplication II.

In both models, Highmark first determines the amount it would have paid as primary. As a secondary payer, Highmark will never pay more than it would have paid as primary.

This means that if the primary "Other Insurance" carrier has paid more than the original Highmark allowance, no additional payment will be made.

The Other Insurance primary payment is deducted from the original Highmark allowance.

In the Soft Non-Duplication I model, this amount is then compared to the Other Insurance member liability. The lesser of the two amounts is considered for payment.

Highmark will apply their group benefits, such as co-payments, coinsurance and deductibles, to any balances after the coordination of benefit methodology is applied.

In the Soft Non-Duplication II model, the Other Insurance primary payment is also deducted from the original Highmark allowance.

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This amount is then compared to the original Highmark payment. The lesser of the two amounts is paid at 100% reimbursement, not to exceed the primary Other Insurance member liability.

If the lesser of the two amounts is greater than the Other Insurance member liability, Highmark will pay the Other Insurance member liability at 100% reimbursement after any copayments are applied.

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When submitting claims to BCBS as a secondary payer, it's essential to include all relevant information from the primary insurer, such as member liability like copayments, coinsurance, and deductibles.

This information is crucial for BCBS to process the claim correctly. BCBS will show the amount the primary insurer paid, if any, on the Explanation of Benefits (EOB), along with the member's liability.

A network provider cannot balance bill the member if BCBS made payment as the secondary payer, except for any copayment, coinsurance, deductible, or non-covered service under the secondary policy.

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To submit a claim to Highmark as the secondary payer, you'll need to include all relevant information from the primary insurer, such as member liability.

This includes details like copayment, coinsurance, and deductible. Make sure to provide all of this information for a smooth claim submission process.

Highmark's Explanation of Benefits (EOB) may or may not show the amount the primary insurer paid, but it will always show the member's liability.

As a network provider, you cannot balance bill the member when Highmark made payment as secondary payer, except for copayment, coinsurance, deductible, or non-covered services under the secondary policy.

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We will pay the balance up to the amount we would have paid if we had been the primary insurer.

Some accounts may elect to use a maintenance of benefits payment calculation, which could result in a lesser payment.

Duplicate payments can be a hassle, and it's great that BCBS has implemented a process to streamline things for providers. The crossover process is a one-step billing system that reduces administrative costs.

This process allows Medicare primary claims to cross over to the BCBS only after the Medicare carrier or intermediary has processed them. The Medicare carrier or intermediary automatically advises the BCBS of Medicare's approved amount and payment for the billed services.

Sending a separate claim and EOMB statement for secondary payment is no longer necessary, and doing so can actually increase costs and slow down claims processing. This is because the BCBS already receives the necessary information from the Medicare carrier or intermediary.

In fact, submitting paper claims and EOMB statements for secondary payment unnecessarily can create confusion for members and increase the volume of claims handled by the secondary payer. This can delay payments and cause unnecessary work for providers.

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As a member of BCBS, it's essential to understand the provider and member information that can help you navigate the coordination of benefits process.

Blue Cross and Blue Shield (BCBS) has a network of over 90,000 providers, including doctors, hospitals, and specialists.

You can find a list of in-network providers on the BCBS website or by calling the customer service number.

BCBS has a unique provider ID for each provider, which is required for billing and claims processing.

BCBS members can access their personalized provider directory on the BCBS website or through the mobile app.

BCBS has a provider directory that includes information on in-network providers, including their specialties, office locations, and contact information.

You can also search for providers by name, location, or specialty on the BCBS website.

BCBS members have access to a 24/7 nurse hotline for non-emergency medical questions and advice.

BCBS offers a variety of tools and resources to help members make informed decisions about their healthcare, including a provider directory and a cost estimator tool.

BCBS members can also contact their employer's HR department or the BCBS customer service number for assistance with finding in-network providers.

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Determining the order of coverage is crucial in BCBS coordination of benefits. The primary coverage bears the majority of the financial responsibility for claim costs.

To determine the primary coverage, you need to apply certain standard rules. Most health insurance carriers, including Highmark, use the following rules: If a person is enrolled in two different plans, the plan that has provided coverage for the longer period of time will be primary.

Here's a quick rundown of the rules for determining primary coverage:

Determining the primary insurer is crucial to understanding who pays for what. Most health insurance carriers use standard rules to decide who is primary.

If a member has coverage as an active employee of one company and is also covered as a retiree or laid-off worker of another company, the benefit plan from their active employment is usually considered primary. This is the case in most situations, but it's essential to check the group contracts.

In some cases, the coverage that has been in force the longest is considered primary. This is a good reminder to review the details of each plan.

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To determine who is the primary insurer, consider the following rules:

These rules can help you determine who is the primary insurer in various situations.

Authorization requirements still apply, even if a benefit plan is secondary or tertiary for the services being reported.

In other words, just because a plan is not the primary one covering a service, it doesn't mean you're off the hook when it comes to getting authorization.

No matter what the coverage order is, you'll still need to follow the authorization requirements for any Highmark benefit plan.

This is a crucial point to keep in mind, as it can affect the services you're able to get and when you can get them.

Even if a service is covered by multiple plans, you'll still need to get authorization from each plan that requires it.

It's always better to err on the side of caution and confirm the authorization requirements for each plan involved.

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Determining Coverage Order is a crucial step in understanding how your benefits work.

Most health insurance carriers, including Highmark, use standard rules to decide who is primary. These rules require applying certain criteria to your situation.

If you're enrolled in two different plans, the plan that has provided coverage for the longer period of time will be primary. This is a straightforward rule that helps determine the order of benefit payment.

Active employee coverage usually takes precedence over retiree or laid-off worker coverage. However, if the group contract doesn't include this provision, the coverage that has been in force the longest is considered primary.

Highmark uses several methodologies when processing claims, but these are only used when they're not the primary payer. These methodologies include the National Association of Insurance Commissioners (NAIC) Model, Regular COB, and others.

Here are the common methods used by Highmark when they're not the primary payer:

Highmark has adopted the NAIC Model COB Regulation, which is the most common methodology used for calculating a secondary payment in COB situations.

This model applies to all commercial group products, as well as institutional claims, professional claims, and ancillary claims. It applies to all health care professionals and providers, regardless of their participating status with Highmark.

The Blue Cross Blue Shield Association supports the NAIC model COB regulation, which is a common industry standard and is consistent with most insurers.

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Policy is all about how insurance companies like Highmark handle claims and payments. Highmark uses a model called Soft Non-Duplication I COB to determine payments.

The Soft Non-Duplication I COB model compares the primary payment from the Other Insurance carrier to the original Highmark allowance. The lesser of the two amounts is considered for payment.

Highmark will never pay more as a secondary payer than it would have paid as primary. This means if the primary carrier paid more than Highmark's original allowance, no additional payment will be made.

The primary payment is deducted from the original Highmark allowance, and any balances remaining are subject to Highmark's group benefits, such as co-payments, coinsurance, and deductibles.

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Highmark has adopted the NAIC Model COB Regulation, which is the most common methodology used for calculating a secondary payment in COB situations.

This regulation applies to all commercial group products, and the majority of commercial business has been moved to the NAIC model.

The NAIC model COB regulation applies to institutional claims, professional claims, and ancillary claims.

It also applies to all health care professionals and providers regardless of their participating status with Highmark.

The Blue Cross Blue Shield Association supports the NAIC model COB regulation, which is a common industry standard and is consistent with most insurers.

Highmark’s senior products, Medicare Advantage products, direct pay products, and the Federal Employee Program (FEP) do not use the NAIC Model.

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