Monday, May 13, 2013

How to deal COB, thirty party liability claims

Coordination of Benefits

Coordination of Benefits (COB) is the process used to process health care payments when a member has coverage with more than one insurer. When it is identified that a member has coverage with more than one insurer:

*  Providers should first submit a claim to identified payers who have primary responsibility for payment of a claim before submitting a claim to SHP

*  When filing a claim to SHP, you must include a copy of the other insurance’s EOB with the claim

*  If SHP is the secondary insurance, SHP will pay the member’s responsibility after the primary insurance carrier has paid, not to exceed SHP’s contracted allowable rate

*  SHP may request a refund for COB claims paid in error for up to thirty (30) months from
the original payment date

Third Party Liability

Subrogation: SHP will pay claims for covered services when probable third party liability has not been established or third party benefits are not available to pay a claim. SHP will attempt to recover any third party resources available to members and shall maintain records pertaining to third party liability collections on behalf of members for audit and review. Coordination of benefits: will be administered in accordance with applicable statutes and regulations

Retroactive Eligibility Changes

A member’s eligibility with a health plan may change retroactively if the individual’s policy or
benefit contract has been terminated, or SHP receives information that the patient is no longer a
member of the Plan, or if the eligibility information we received turned out to be untrue.

A claim adjustment may be necessary if you have had claims in which the members have had
retroactive eligibility changes. The EOB or PRA will show the reason for the claim adjustment.

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