Coordination of Benefits | CMS

coordination of benefits (cob) allows plans that provide health and/or prescription coverage for a person with medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has primary payment responsibility and in how much the other plans will contribute when a person is covered by more than one plan).

the process of the cob:

• ensures that claims are paid correctly by identifying the health benefits available to a medicare beneficiary, coordinating the payment process, and ensuring that the primary payer, whether medicare or other insurance, pays first.
• shares medicare eligibility data with other payers and transmits claims paid by medicare to supplemental insurers for secondary payment. note: there must be an agreement between the coordination of benefits & amp; recovery center (bcrc) and private insurance companies so that the bcrc automatically crosses claims. in the absence of an agreement, the person with medicare must coordinate the secondary or supplemental payment of benefits with any other insurer they may have in addition to medicare.
• guarantees that the amount paid by the plans in situations of double coverage does not exceed 100% of the total claim, to avoid duplicate payments.
• accommodates all part d benefit coordination needs. The COB process provides the Out-of-Pocket Facilitation Contractor (TROOPS) and Part D Plans with the secondary non-Medicare prescription drug coverage they must have to facilitate payer determinations and the accurate calculation of Troop expenses. of the beneficiaries; and allowing employers to easily participate in the Retirement Drug Subsidy (RDS) program. Click on the Coordination of Prescription Drug Benefits link for additional information.

COB data sources

cob is based on many databases maintained by multiple stakeholders, including federal and state programs, plans that offer health and/or prescription insurance coverage, pharmacy networks, and a variety of assistance programs available for specific situations or conditions. specials. some of the methods used to obtain information from the cob are listed below:

Reading: What is cob for insurance

Voluntary Data Sharing Agreements (VDSAS): CMS has entered into VDSAS with numerous major employers. These agreements allow employers and CMS to electronically send and receive group health plan enrollment information. When vDSA discrepancies occur, employers may provide enrollment/disenrollment documentation. vdsa’s data exchange process has been revised to include part d information, allowing vdsa partners to submit records with either primary or secondary prescription drug coverage to part d. employers with vdsas can use vdsa to submit their retiree prescription drug coverage population, supporting cms’ mission of a single point of contact for entities that coordinate with medicare. click the voluntary data sharing agreements link for additional information.

cob agreement program (coba): cms consolidates the cross-processing of claims paid by medicare through the coba program. the coba program established a national standard contract between bcrc and other health insurance organizations to transmit member eligibility data and claims data paid by medicare. This means that medigap plans, part d plans, employer supplemental plans, self-insured plans, the department of defense, state title xix medicaid agencies, and others rely on a national repository of information with unique identifiers to receive paid claims data from medicare for the purpose of calculating your secondary payment. Coba’s data sharing processes have been revised to include prescription drug coverage.

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section 111 of the medicare, medicaid and schip extension act of 2007 (mmsea): this act added mandatory reporting requirements for group health plan (ghp) arrangements and for group health insurance liability, including insurance, no-fault insurance, and workers’ compensation. insurers are legally required to provide information.

Other Data Exchanges: CMS has developed data exchanges for entities that have not coordinated benefits with Medicare before, including pharmacy benefit managers (pbms), state pharmaceutical assistance programs (spaps), and other prescription medications. payers cms has worked with these new partners to educate them on coordination needs, to inform cms about how the world of prescription drug benefits works today, and to develop data exchanges that allow all parties to serve efficiently to our common client, the beneficiary.

cob entities

coordination of benefits & recovery center (bcrc) – the bcrc consolidates the activities that support the collection, management and reporting of other insurance coverage for beneficiaries. The BCRC takes steps to identify the health benefits available to a beneficiary and coordinates the payment process to prevent erroneous payment of Medicare benefits. The BCRC does not process claims, nor does it handle any ghp-related erroneous payment recovery or claim-specific enquiries. Medicare Administrative Contractors (MACs), brokers, and carriers are responsible for processing claims submitted for primary or secondary payment.

the bcrc is responsible for the following activities:

• Initiate an investigation when it is known that a person has other insurance. The investigation determines whether Medicare or other insurance has the primary responsibility for covering the beneficiary’s health care costs.
• Collection of information on employer group health plans and non-group health plans liability (including self-insurance), no-fault insurance, and workers’ compensation), and updating this information in Medicare databases whenever a change in insurance coverage is made. information comes from these sources: beneficiary, physician/service provider, employer, ghp, liability, no-fault and workers’ compensation entity, and attorney.
• establish msp occurrence logs in cwf for prevent Medicare from paying when another party must pay first. The CWF is a single data source for fiscal intermediaries and carriers to verify beneficiary eligibility and conduct prepayment review and claims approval from a national perspective. it is the only place in the fee-for-service claims processing system where complete individual beneficiary information is housed.
• transmitting other health insurance data to the medicare beneficiary database (mbd ) for the proper coordination of rx benefits.
• recovery of erroneous payments related to a non-group health plan (nghp) where the beneficiary must pay medicare. see the non-group health plan recovery page for additional information.

once the bcrc has completed its initial msp development activities, it will notify the commercial payment center (crc) of ghp msp incidents and nghp msp incidents where a liability insurer ( including a self-insured entity), a no-fault insurer or workers’ compensation entity is the identified obligor. the bcrc will retain responsibility for nghp msp cases where medicare seeks reimbursement from the beneficiary.

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when to contact the bcrc:

• to report changes in employment, or any other insurance coverage information.
• to report a liability, auto/no-fault, or workers’ compensation case.
• to ask a general question about the msp.
• to ask a question about the msp letters and questionnaires (ie, the secondary claims development [scd] questionnaire). For more information, click the link to report other health insurance.

see the contacts page for bcrc’s phone numbers and mailing address.

commercial payment center (crc): the crc is responsible for all functions and workloads related to ghp msp recovery with the exception of provider, physician or other provider recovery . The CRC is responsible for identifying and recovering erroneous Medicare payments where a GHP has primary payment responsibility. Some of these responsibilities include: issuing a Primary Payment Notice (PPN) to verify MSP information, issuing recovery demand letters when erroneous primary payments are identified, receiving payments, resolving outstanding debts, and referring delinquent debts to the treasury department for additional collection actions, including treasury compensation program, as applicable. see the group health plan recovery page for additional information.

The CRC will also perform nghp recovery where the identified debtor is a liability insurer (including a self-insured entity), a no-fault insurer, or a workers’ compensation entity. see the non-group health plan recovery page for additional information.

Medicare Contractors: Medicare contractors (ie, MACs, brokers, and carriers) are responsible for processing claims submitted for primary or secondary payment. These entities help ensure that claims are paid correctly when Medicare is the secondary payer. They use information on the claim form and in CMS data systems to avoid making primary payments in error. Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as primary payer and will return it to the service provider with instructions to bill the appropriate party.

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