Tami,
As stated in the question, (for whatever reason). Many providers have payers that
(for whatever reason; cost, low volume, special cases) they do not deal with
electronically. The provider has no control over which model COB they follow. I
reference the Final Rule from the Federal Register, page 50336, middle column:
"...Response: Coordination of Benefits
can be accomplished in two ways, either
between health plans and other payers
(for example, an auto insurance
company), or from a health care
provider to a health plan or other payer.
The choice of model is up to the health
plan.
Under this rule health plans are only
required to accept COB transactions
from other entities, including those that
are not covered entities, with which
they have trading partner agreements to
conduct COB. Once such an agreement
is in place, a health plan may not refuse
to accept and process a COB transaction
on the basis that it is a standard
transaction. For example, a health plan
receives a standard ASC X12N 837
transaction from a health care provider
with which it has a COB trading partner
agreement. If the health plan is not the
primary payer, it must accept and
process the COB information to
adjudicate the claim. If the health plan
has decided to conduct COB
transactions with another payer, it must
accept and store the COB information to
use in a COB transaction with the other
payer. If the health plan is the primary
payer and does not have a trading
partner agreement with the secondary
payer, then it may simply dispose of the
COB information and leave the COB
activity up to the health care provider...."
Thanks for your thoughts on this.
Jon
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>>> [EMAIL PROTECTED] 03/29/02 11:43AM >>>
Why would the balance to payor B be paper?
The provider should be following model 2 of the COB process.
Tami Leaver
Sr. Application Analyst
Medstar Information Systems
410-933-6905
email: [EMAIL PROTECTED]
"Jonathan Fox"
<JFOX%independenthealth.com@interne To:
<[EMAIL PROTECTED]>
t.mhg.edu> cc:
Subject: COB
Explanation of Benefits
03/29/02 09:12 AM
Please respond to
transactions%wedi.org
I have a question regarding Explanation of Benefits in an 837 environment.
"Provider submits an 837 claim to Payer A. Payer A sends back an 835
electronic remit. Balance to Payer B has to be submitted on a paper
claim form. (for whatever reason) Payer B requires that an explanation of
benefits is sent along with the claim. What does the provider send to
Payer B if there is no hardcopy of the 835 remit?"
Any thoughts or suggestions would be very helpful.
Thanks.
Jon Fox
eCommerce Analyst
Independent Health
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the e-mail and its attachments from your computer. Thank you for your
attention.
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