How to resolve coordination of benefits?

To fix a coordination of benefits (COB) issue, you must update your insurance companies with your correct primary and secondary coverage order so they can reprocess your denied or pending claims.

Step-by-Step Fix

• Find the numbers: Grab your insurance cards and look for the Member Services or COB phone number listed on the back.
• Call your primary insurer first: Tell the representative you need to update your COB information and confirm they are listed as your primary (first-paying) insurance.
• Call your secondary insurer: Contact your second insurance plan to give them the details of your primary plan. Ask them to update their records and link the primary.
• Get reference numbers: Write down the name of each representative you speak with and the call reference numbers for your records.
• Notify your provider or billing office: Send the primary insurance details, the names of the reps, and the reference numbers to your doctor's billing department so they can resubmit or supplement the claim.

Common Rules for Who Pays First

• Your own job: Your employer-sponsored plan is primary over a plan where you are covered as a dependent or spouse.
• The birthday rule: For children covered under both parents, the parent whose birthday falls earlier in the calendar year has the primary policy.
• Medicare: Medicare is usually secondary if you have active group health insurance through an employer with 20 or more employees.

The 7 rules of Coordination of Benefits (COB) in health insurance and medical billing determine which insurance plan pays first (primary) and which pays second (secondary) when a patient has multiple plans.

The 7 Core COB Rules

• Rule of Policyholder (Subscriber): The plan that covers the patient as the main employee or subscriber is primary, while the plan that covers them as a dependent is secondary.
• Birthday Rule: For a dependent child covered by both parents, the parent whose birthday falls earlier in the calendar year (month and day, not year) has the primary plan.
• Custodial Parent Rule: For children of divorced or separated parents, the plan of the custodial parent pays first, followed by the non-custodial parent's plan (unless a court decree states otherwise).
• Active Employee vs. Retiree Rule: An active employee's insurance plan is primary over an insurance plan the person holds as a retiree or through COBRA continuation coverage.
• Medicare Secondary Payer (MSP) Rule: Determines when Medicare is primary or secondary—such as when a person is over 65 but still actively working under a large group health plan, making the employer plan primary and Medicare secondary.
• Continuation Coverage Rule (COBRA Rule): A plan covering a person as a COBRA continuation participant is secondary to a plan that covers the person as an active employee or dependent.
• Length of Coverage (Timeline) Rule: If none of the other rules apply, the plan that has covered the patient or policyholder for the longest consecutive period of time pays as the primary insurance.

You can read more detailed breakdowns of these guidelines through the COB in Medical Billing Guide.

Coordination of benefits (COB) issues happen when multiple insurance plans fail to align correctly on who pays first, leading to delayed payments, claim rejections, and unexpected patient bills.

Common Issues and Causes

• Outdated or Missing Information: Patients often forget to disclose secondary coverage or fail to update changes with their insurer, causing records to mismatch between payers.
• Wrong Billing Order (CO-22 Denials): Submitting a claim to the secondary insurance first prompts payers to reject it until the primary plan processes the charge.
• Medicare and Employer Confusion: Determining whether Medicare or an employer group health plan is primary depends heavily on company size (such as the 20-employee rule) and retirement status, which frequently gets miscalculated.
• Timely Filing Expirations: Lengthy back-and-forth disputes between insurers can push past the strict deadlines allowed for submitting clean claims.

How to Prevent and Resolve COB Problems

• Verify at Intake: Collect complete dual-coverage details and employer sizes during every patient registration.
• Prompt Patient Updates: Instruct patients to contact their member services immediately to update their active order of liability when policies change.
• Follow Standard Rules: Apply clear COB in Medical Billing Rules like the birthday rule for children or active-versus-retiree guidelines to sequence payers accurately.

The four types of coordination of benefits (COB) are Standard (or Traditional), Maintenance, Non-Duplication, and Do Not Coordinate Benefits.

Coordination of benefits dictates how multiple insurance plans share payment responsibilities so that combined payouts do not exceed total medical or dental costs.

1. Standard (Traditional) COB

• How it works: The primary plan pays its normal benefits first. Then, the secondary plan covers the remaining balance up to 100% of the total allowable expenses.
• Result: The patient rarely pays out-of-pocket for covered services as long as the combined secondary payout covers the remainder.

2. Maintenance COB

• How it works: The secondary plan calculates what it would have paid if it were the primary plan. It then reduces that amount by subtracting what the primary plan already paid.
• Result: The secondary plan only pays whatever positive difference remains, without topping off the remaining balance completely.

3. Non-Duplication COB

• How it works: The secondary plan looks at the primary plan's payment. If the primary plan's payment equals or exceeds what the secondary plan would have normally paid on its own, the secondary plan pays zero.
• Result: The patient receives no extra coverage from the secondary plan if the primary plan already paid a higher percentage or equal amount for that specific service.

4. Do Not Coordinate Benefits

• How it works: The secondary plan refuses to coordinate or factor in what the primary insurance paid. Each plan processes the claim independently based on its own rules.
• Result: This can sometimes lead to a denial of secondary payment or strict separate limits, depending on the specific group contract terms.

You can read more about guidelines and rules for managing claims through the American Dental Association or Centers for Medicare & Medicaid Services.

To do a coordination of benefits (COB), you must notify all of your insurance companies about your other active coverage so they can determine which plan pays first.

Steps to Set Up and Process COB

• Notify your insurers: Contact each insurance company via phone, online portal, or by filling out a mailed COB form to disclose all active health plans. You must do this when you enroll, when coverage changes, and typically during annual plan renewals.
• Determine payment order: Insurers figure out which plan is primary (pays first) and which is secondary (pays remaining balances). The primary plan pays up to its coverage limits first.
• Submit the primary claim: File the medical claim with the primary insurance provider.
• Receive the primary EOB: Wait for the primary insurer to process the claim and issue an Explanation of Benefits (EOB) showing what they paid.
• Submit the secondary claim: File a claim with the secondary insurance plan, including a copy of the primary insurer's EOB so they can review the remaining balance. The secondary plan pays its share of what is left, but combined payments will never exceed 100% of the total medical cost.

General Rules for Payment Order

• Your own plan vs. dependent plan: The plan covering you as an active employee or main policyholder is primary over a plan covering you as a dependent or spouse.
• Active vs. retired/COBRA: Active employee coverage is primary over retired employee coverage or COBRA.
• Children (Birthday Rule): For dependent children covered under both parents' plans, the parent whose birthday falls earlier in the calendar year is primary.
• Medicare and other insurance: Check specific government guidelines like Medicare Coordination of Benefits to see whether Medicare or your group health plan pays first. You can also review general procedures via the Centers for Medicare & Medicaid Services.