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Coordination of Benefits

Under HIPAA, HHS adopted standards for electronic transactions, including for coordination of benefits.

The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of a health plan for health care claims or payment information.

About Coordination of Benefits

Coordination of benefits (COB) applies to a person who is covered by more than one health plan.

The COB regulations require that all health plans and other payers (e.g., Medicaid and Medicare) coordinate benefits to eliminate duplication of payment and help patients receive the maximum benefit they are allowed.

COB claims are those sent to secondary payers with an attached or included explanation of payment information from the primary payer (the health plan or payer obligated to pay a claim first). These claims can be sent 1) from provider to payer to payer or 2) from provider to payer.

HIPAA Adopted Standards

In January 2009, HHS adopted Version 5010 of the ASC X12N 837 for coordination of benefits.

For COB pharmacy claim transactions, HHS adopted NCPDP Telecommunications Standard Version D.0. 

These standards apply to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.

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