When a member has two active health plans with Regence, the member is considered to have secondary (or dual) coverage. Currently, we manually copy the information from the primary claim into the secondary claim for processing.
Beginning in July 2022, once the primary claim has finished processing, we will automatically copy the primary claim into the secondary claim for processing. This will expedite processing for most secondary claims.
- Please allow 30 days from the date the claim processed on the primary plan to be transferred and processed to the secondary. You can check the status of your claims on Availity Essentials.
- You may see denials for claims that have already been processed (e.g., duplicate claims).
This impacts commercial (medical and dental) and Medicare claims.
Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under, while ensuring that the total combined payment from all sources is not more than the total charge for the services provided.
When your patient has coverage under two or more payers, the primary plan will pay benefits first, with secondary and tertiary plans considering any remaining unpaid, eligible balances. When Asuris is the secondary or tertiary plan, you should submit the claim to the primary plan first. When you have received a claims processing voucher from the primary plan, please submit the claim with the primary and/or secondary information electronically to Asuris, identifying all insurance coverage information on each claim.
We require electronic submission of COB claims using standard Health Insurance Portability and Accountability Act (HIPAA), American National Standards Institute (ANSI) formats for both institutional and professional COB claims. This applies to all Asuris products, including Medicare Advantage.
To ensure electronic COB claims are processed correctly, complete all other insurance fields and use the submission guidelines in the Implementation Guide (IG) Registry, including:
** Amount paid
** Patient balance
** Amount the other carrier approved
Please ensure all COB claims are submitted with the appropriate Claim Adjustment Reason Code and corresponding Group Code.
Claim Adjustment Reason Codes and Claim Adjustment Group Codes are used in COB transactions to:
** Assign responsibility for the adjustment amount
** Communicate how a claim or service line was paid
When submitting an electronic claim to a secondary payer, it must include the two alpha character Claim Adjustment Group Code followed by the numeric Claim Adjustment Reason Code. The alpha characters explain who is responsible for the adjusted amount, and the numeric value provides a description of the adjustment amount (e.g., PR1, CO45).
We recently identified provider billing discrepancies regarding the Claim Adjustment Reason Codes and Group Code compatibility on claims.
The discrepancies include:
** Holding the member liable for the Medicare Sequestration amount when the provider accepts Medicare assignment.
** Billing claim adjustment group code Contractual Obligation (CO) in conjunction with claim adjustment reason codes that indicate the amount is patient responsibility (e.g., deductible, copayment or coinsurance.) Note: Contractual Obligation (CO) indicates provider responsibility and Patient Responsibility (PR) indicates the member is responsible for the charges.
Claim Adjustment Reason Codes and Group Code discrepancies will result in:
** Holding the member or provider liable in error
** Over or under payment by the secondary insurance carrier
** Holding the member or provider liable for the incorrect amount
** Holding the member or provider liable in error
** Over or under payment by the secondary insurance carrier
** Holding the member or provider liable for the incorrect amount
View Claim Adjustment Reason Codes and Group Code indicators on the Washington Publishing Company website.
If you have questions about submitting electronic COB claims, please contact your software vendor or software support.
Additional information about submitting secondary claims electronically is available on the OneHealthPort website.
To comply with a rule issued by the Office of the Insurance Commissioner (OIC), we no longer estimate secondary payer payments if the primary payer's payment amount is unknown. This rule applies to all employer groups and Individual plans. However, Employee Retirement Income Security Act (ERISA) self-funded groups and Medicare plans are exempt.
Maintenance of Benefits (MOB) lets your patients receive benefits from all payers they are covered under, while maintaining the patient's responsibility for coinsurance and/or copayment amounts and ensuring that the total combined payment from all sources is never more than the total charge for the services.
With MOB processing, secondary payers only allow benefits up to their own maximum allowable for the specific service(s). If the primary payer's payment is equal to or greater than what the secondary payer's payment would have been as primary, no additional benefits will be remitted. This can result in members having out-of-pocket expenses, something not usually seen with COB processing.
Your patient should complete our member COB questionnaire (PDF) when covered by more than one health insurance policy. This will help us process claims correctly.
Note:
** The member must complete and sign the form.
** Submit the completed form to:
Asuris Northwest Health
Attention: CPSS COB Research
P.O. Box 1106
Lewiston, ID 83501
When Medicare is the primary payer for an out-of-area member (e.g., Medigap plans), follow these procedures:
- Submit claims to your local Medicare contractor first. Do not send the claim to Medicare and the supplemental insurer simultaneously. Be sure to include the:
- Patient's complete member number
- Patient's name as it appears on the member card
- Complete Medicare Beneficiary Identifier (MBI)
- Other payer's name and address (OCNA) number. If you include this information, make sure it is the correct OCNA for the member's health plan
After you receive the Explanation of Medical Benefits (EOMB) or payment advice from Medicare, determine if the claim was automatically crossed over to the supplemental insurer:
- Crossed over: If the indicator on the EOMB or payment advice shows that the claim was crossed-over (claim status code 19: "Medicare paid primary and the Intermediary sent the claim to another insurer"), Medicare has forwarded the claim on your behalf to the appropriate health plan and the claim is in process. You do not need to file for the Medicare supplemental benefits. The Medicare supplemental insurer will automatically pay you if you accepted Medicare assignment. Otherwise, the member will be paid and you will need to bill the member.
- Not crossed over: If the indicator on the EOMB or payment advice does not indicate the claim was crossed over (claim status code 1: "Paid as primary" may appear; claim status 19 will not appear), file the claim and the payment advice to Asuris. Asuris or the member's health plan will pay you the Medicare supplemental benefits. If you did not accept Medicare assignment, the member will be paid and you will need to bill the member.
When another health plan is the primary payer (e.g., Medicare Advantage), submit claims to Asuris. Do not bill Medicare directly for any services rendered to a Medicare Advantage member.
Employed persons age 65 and over, and their eligible dependents age 65 and over, may be covered by their employer's health plan and Medicare.
To find out whether Medicare is primary or secondary:
- Call Provider Contact Center
- Ask the member to check with his or her employer
- Call the Medicare Coordination of Benefits Contractor (COBC) at 1 (800) 999-1118
Submit claims to us in the usual manner – if we are not primary, we will notify you that Medicare must be billed first
The Tax Equity and Fiscal Responsibility Act (TEFRA), requires that employers with 20 or more employees offer employees age 65 and older the same health care plan that is offered to younger employees and their families. In these cases:
- Submit Asuris member claims to us
- The employer plan pays primary to Medicare
After processing the claim, Medicare should be billed for unpaid amounts that are the member's responsibility
Submit the claim to Medicare first for payment if the member is covered by Medicare and an Asuris Pledge Medicare supplement product, a Asuris group or Individual product with less than 20 employees or by a retiree plan.
Medicare beneficiaries may have an Asuris group contract or one of our Individual Asuris Pledge Medigap supplements, secondary to Medicare. All charges not paid by Medicare are considered for payment. These include:
- Charges excluded by Medicare
- The 20% coinsurance on assigned claims
- Charges applied to the Medicare deductible
All balances after Medicare payment (unassigned claims)
If an individual has Medicare and elects COBRA coverage, both coverages are allowed. If an individual has COBRA coverage and subsequently becomes entitled to either Medicare Part A or Part B, the COBRA coverage terminates on the date that Medicare becomes effective.
Note: If Medicare is in effect and COBRA is elected, Medicare is normally primary even if the group is TEFRA or OBRA eligible (the exception is end stage renal disease).
- Persons under 65 who are covered by Medicare due to disability or ESRD may also be covered through an employer group health plan that has 100 or more employees is OBRA eligible. The group plan is primary over Medicare.
- A person who has Medicare due to disability and is covered as either a subscriber or dependent by an employer group health plan that has less than 100 employees is not OBRA eligible. Medicare is primary over the group plan.
- When a person who has Medicare due to ESRD also is covered by a group employer plan, the group employer plan is normally considered as primary for the first 30 months. Once the 30 months EPGH period is met, Medicare becomes the primary payer and the employer group plan becomes secondary.
A claim could be held for possible other party liability review (OPL) for multiple reasons. Reasons may include:
- Services related to a work or auto accident
- Services related to a known injury or accident
- Combination of dollar amount and diagnosis code billed
- Services related by body area to an open or ongoing investigation
Accident indicator on claim of auto, work, or work related auto accident
Notes:
- This list is a general informational and not all inclusive
OPL claims are not subject to timely claims filing, and are therefore not subject to adjustment timelines
If a claim is held for accident information from the member, the member needs to follow directions indicated on the letter he or she received from us or from our contracted vendor. This will consist of either an incident report, or a letter to call our vendor to provide information about the claim that is considered a potentially a third-party situation.
When an accident investigation is created, claims related to those services will pend in our claims system for up to 25 days. If the information is not received within 25 days, the investigation will close with the claim remark indicating information is required from the member. The closed claim will become member responsibility.
It is possible that an accident investigation has already been initiated and the submitted claim is related to information we already have a pended investigation on file. In this situation the claim will be attached to the pended accident investigation and held until requested information has been received or the 25 day time period is met with no information being received.
Note: The 25 days limit commences from the day the investigation is created in our system.
Based on the claim denial reason the member may need to either:
- Contact our trusted vendor to provide the requested incident report information (reason codes O3X, O4J, O4K, O3W, O4G, O4H, O39, O4P, O4N)
- If the member contacts Customer Service, he or she will be asked to contact the vendor directly, if he or she has not already done so.
- If the member has contacted the vendor first and then contacts our Customer Service, he or she will be transferred to the OPL department.
Complete and return the incident report to the Health Plan (if reason code is O1V, O3D or O1D)
- If you have questions, contact the Provider Contact Center at the phone number indicated on the back of the member ID card
The claim closure codes, including those above, will help determine how the member needs to return the required information. The member can contact Customer Service with questions or he or she can complete an Incident Report on our member website.