Coordination of Benefits

What is Coordination of Benefits (COB) - Cross Over Claims - and how it works?

COB is a process, which allows Medicare to electronically forward claims to insurance carriers and other government agencies, such as Medicaid. These insurance carriers and government agencies are generally referred to as "Trading Partners". Some of our Trading Partners are data clearinghouses, which forward the claim data to additional insurance carriers.

The cross over process begins with an eligibility file, which is forwarded to us by the individual Trading Partners. The eligibility files are generally provided to us on a weekly or sometimes monthly basis and contain the Health Insurance Claims Number (HICN) of all beneficiaries, who have Medicare as their primary coverage, and secondary or tertiary coverage through the Trading Partner. Once the eligibility files are applied to our system, all HICNs of claims processed by us are compared with the eligibility file. When a match is found during the compare process, the claim is copied to the Trading Partner's cross over file, and is forwarded to the Trading Partner on a daily or sometimes weekly basis. A claim can only be forwarded to one Trading Partner, even when a HICN appears on more than one eligibility file.

Claims for beneficiaries, whose HICNs are not on the eligibility files, will not get crossed over to the Trading Partner. This applies, even if the claims contain information about secondary or tertiary coverage. In the case that an individual has multiple supplemental insurance carriers, and the individual may be on more than one eligibility file, we can only cross claims over to the first Trading Partner on our file.

While the key to the cross over process is the eligibility file, we want to encourage all providers to continue supplying all known insurance information on the claim. In fact, some Trading Partners rely on this information in order to process the claim in their system. Supplying secondary or tertiary insurance information whenever possible may prevent you from investigating the path of the claims and from filing paper claims with the other insurer. We are forwarding all insurance related information that was supplied to us to the Trading Partners. However, if we receive claims without other coverage information, we cannot add this information to the claims.

It is our understanding that some Trading Partners will deny claims that do not have secondary insurance information at the time that they receive the claim through the cross over process. Since we are forwarding the claims to the Trading Partners with the same information that was supplied to us, you may wish to review how the claim was submitted to Medicare when you receive denials from the Trading Partners, requesting this information.

Yet other Trading Partners will not allow claims that do not have their particular company listed as one of the payers to enter their adjudication system. Some of these Trading Partners may send a notification to the providers, advising you that the claim should be submitted in paper format. Other Trading Partners, however, do not have a notification system in place. In fact, their customer service representatives often do not have access to this information and will erroneously advise you that their company did not receive the claims from Medicare.

Please be advised that we are crossing the claim over in the same way we received it from you. Crosswalks from the HIC number to the Trading Partner's identification number, as well as crosswalks from your Medicare provider number to your provider number with the Trading Partner take place at the Trading Partner. Therefore, if your Medicare provider number or tax identification number has changed, you may want to consider notifying the Trading Partners to avoid any problems that may occur as a result of this.

Remote FISS (the Fiscal Intermediary Standard System) allows you to view, if a claim has crossed over to one of our Trading Partners: The payment section on page #6 of the FISS contains a field named "CROSSOVER IND". If this field is blank, the particular claim was not crossed over to any of our Trading Partners. However, if this field is populated with the value "1", the claim was forwarded to the Trading Partner identified in the field named "PARTNER ID". (The "PARTNER ID" field is typically comprised of the first initial of the Trading Partner's name their zip code and a three digit qualifier.)

Claims, which were crossed over to other insurance carriers can be identified by the remark code "MA01" on the Medicare Remittance Advice's. All claims with a value of "1" in the "CROSSOVER IND" field of the FISS, or with a remark code of "MA01" are forwarded to one of the Trading Partners.

As mentioned before, there are situations where the Trading Partner that received the claims may not be able to read all claims that they receive from us into their system for processing. If this applies, you may wish to contact the Trading Partner for further advice on how to proceed. Please keep in mind though, that if the claim was rejected from entering the Trading Partner's claims system, their customer service representatives will not be able to see the claim. The Trading Partner's customer service representatives may therefore incorrectly assume that their company did not receive the claim. If you want to pursue such instances, you may need to ask for the situation to be referred to the Trading Partner's systems department for research.

Reasons for claims not to Cross Over

1. Beneficiary is not on the Eligibility File we received from the Trading Partner.
2. Beneficiary was on the Eligibility File, but additional matching criteria were not met (Dates of Service on the bill not within range of Eligibility, Type of Bill not processed by this Trading Partner, etc.).
3. Beneficiary is on more than one Eligibility File (Claim can only be crossed to the first Trading Partner on file).

Reasons for Trading Partners not to process Claims that were Crossed Over

1. Claim was submitted without secondary coverage information.
2. Claim contains data that is edited from entering the Trading Partner's system (HCPC/Revenue codes not defined to the Trading Partner's system, Medicare Provider Number not on file with the Trading Partner, etc.).

In summary:

1. The Cross Over process is 100% driven by the Eligibility Files that the Trading partners supply to UGS.
2. During our processing, the claims get compared to the Eligibility Files. Any matches found are written to the Cross Over Files.
3. The Trading Partners receive the Cross Over Files and the Providers receive R/As with Remark Code MA01.
4. During their processing, the Trading Partners cross walk Medicare data (provider #, HIC #) into their corresponding information.
5. While other coverage information does not trigger the Cross Over process, some Trading Partners require this information in order to process the claims in the Cross Over Files.