Coordination of Benefits Overview
The Coordination of Benefits Contractor (COBC) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purpose of the COB program is to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken Medicare payment. The COBC does not process claims, nor does it handle any mistaken payment recoveries or claim-specific inquiries. The Medicare Administrative Contractors, (MACs), intermediaries, and carriers are responsible for processing claims submitted for primary or secondary payment and resolving situations where a provider receives a mistaken payment of Medicare benefits.
All Medicare Secondary Payer (MSP) claims investigations are initiated from and researched by the COBC, and is not a function of the local Medicare claims paying office. This single-source development approach greatly reduces the number of duplicate MSP investigations. This also offers a centralized, one-stop customer service approach for all MSP-related inquiries, including those seeking general MSP information. The COBC provides customer service to all callers from any source, including, but not limited to, beneficiaries, attorneys/other beneficiary representatives, employers, insurers, providers, and suppliers.
Medicare generally uses the term Medicare Secondary Payer or "MSP" when the Medicare program is not responsible for paying a claim first. The COBC uses a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare. For example, information submitted on a medical claim or from other sources may result in an MSP claims investigation that involves the collection of data on other health insurance. In such situations, the other health plan may have the legal obligation to meet the beneficiary's health care expenses first before Medicare. For more information about Medicare Secondary Payer and the providers’ role in collecting data to ensure they are billing the correct primary payer, please see the Medicare Secondary Payer Fact Sheet available in the Downloads section below.
Provider Requests and Questions Regarding Claims Payment
MACS, intermediaries, and carriers will continue to process claims submitted for primary or secondary payment. Claims processing is not a function of the COBC. Questions concerning how to bill for payment (e.g., value codes, occurrence codes) should continue to be directed to your local Medicare claims paying office. In addition, continue to return inappropriate Medicare payments to the local Medicare claims office; checks should not be sent to the COBC. Questions regarding Medicare claim or service denials and adjustments should continue to be directed to your local Medicare claims office. If a provider submits a claim on behalf of a beneficiary and there is an indication of MSP, but not sufficient information to disprove the existence of MSP, the claim will be investigated by the COBC. This investigation will be performed with the provider or supplier that submitted the claim. The goal of MSP information gathering and investigation is to identify MSP situations quickly and accurately, thus ensuring correct primary and secondary payments by the responsible party.
Medicare Secondary Payer Records in CMS's Database
The COBC is the sole authority to ensure the accuracy and integrity of the MSP information contained in CMS's database (i.e., Common Working File (CWF)). Information received because of MSP data gathering and investigation is stored on the CWF. MSP data may be updated, as necessary, based on additional information received from external parties (e.g., beneficiaries, providers, attorneys, third party payers). Beneficiary, spouse and/or family member changes in employment, reporting of an accident, illness, or injury, Federal program coverage changes, or any other insurance coverage information should be reported directly to the COBC. CMS also relies on providers and suppliers to ask their Medicare patients about the presence of other primary health care coverage, and to report this information when filing claims with the Medicare program.
Termination and Deletion of MSP Records in CMS's Database
Medicare claims paying offices can terminate records on the CWF when the provider has received information that MSP no longer applies (e.g., cessation of employment, exhaustion of benefits). Termination requests should be directed to your Medicare claims payment office. MSP records that you have identified as invalid are reported to the COBC for investigation and deletion.
Contacting the COBC
The COBC’s trained staff will help you with your COB questions. Whether you need a question answered or assistance completing a questionnaire, the Customer Service Representatives are available to provide you with quality service. Click the Contacts link in the Related Links section below for COBC contact information.
In order to better serve you, please have the following information available when you call:
- Your Medicare provider number (UPIN/OSCAR/NSC). If you cannot furnish a provider number that matches the COBC’s database, you will be asked to submit your request in writing. Prior to releasing any Private Health Information about a beneficiary, you will need the beneficiary's last name and first initial, date of birth, HIC number, and gender. If you are unable to provide the correct information, the COBC cannot release any beneficiary specific information. You will be advised that the beneficiary's information is protected under the Privacy Act, and the COBC will not release the information. The COBC will only provide answers to general COB or MSP questions. For more information on the COBC, click the Coordination of Benefits link found in the Related Links section below.
Note: The COBC will be unable to provide the following:
- Information regarding beneficiary entitlement data. Current regulations do not allow the COBC to provide entitlement data to the provider.
- Insurer information. The COBC is permitted to state whether Medicare is primary or secondary, but cannot provide the name of the other insurer. It is very important that the provider obtain this information from the beneficiary, since the Privacy Act prohibits the release of this information.
Contacting the Medicare Claims Office
Contact your local Medicare Claims Office to:
- Answer your questions regarding Medicare claim or service denials and adjustments.
- Answer your questions concerning how to bill for payment.
- Process claims for primary or secondary payment.
- Accept the return of inappropriate Medicare payment.
COBA Trading Partner Contact Information
The Coordination of Benefits Agreement (COBA) Program establishes a nationally standard contract between CMS and other health insurance organizations that defines the criteria for transmitting enrollee eligibility data and Medicare adjudicated claim data. CMS has provided a COBA Trading Partners customer service contact list as an avenue for providers to contact the trading partners. The COBA Trading Partners document in the Download section below provides a list of automatic crossover trading partners in production, their identification number, and customer contact name and number. For additional information, select the COBA Trading Partners link found in the Related Links section below.
Medlearn Matters – Provider Education Articles
The Medicare Learning Network (MLN) is a CMS initiative to ensure Medicare physicians, providers and supplies have immediate access to Medicare coverage and reimbursement rules in a brief, accurate, and easy to understand format. To access MLN Matters articles, click on the MLN Matters link found in the Related Links section below.
Web Site Update Notifications for Providers
CMS provides the ability for you to be automatically notified when changes are made to the Provider Services Web pages. If you have not already signed up for these notifications, please click the Subscription Sign-up for Provider Services Web Page Update Notification link found in the Related Links section below to subscribe to Providers Web page updates. When notifications and new information regarding Provider Services are available, you will be notified. These announcements will also be posted to the What’s New page.
- Page last Modified: 07/02/2013 1:31 PM
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