COBC

1
COBC

• Coordination Of Benefits Contractor
• (electronic crossover)
• Randall Watkins, UGS, 10/8/04

2
Distant Past

• The FI (UGS) receives and processes claim from
  Provider
• Data on claim indicates secondary payer
• Claim has deductible or coinsurance
• Claim is selected, formatted, and sent
  electronically to Payers with whom the FI (UGS)
  has an agreement (TPA)

3
Current

• The FI (UGS) receives and loads into FISS an
  Eligibility file from the Payers with whom the FI
  has an agreement (TPA)
• The FI (UGS) receives and processes claim from
  Provider
• Claim matches data on Payers Eligibility file
  and meets Payers selection criteria.
• Claim is selected, formatted, and sent
  electronically to Payer.

4
Current Notes

• Prior to January 1, 2004, regardless of how many
  Payer eligibility matches were present in the
  tables for a single Beneficiary, only the first
  match produced a claim for crossover
• January 1, 2004 and after, per CMS instructions,
  a crossover claim was produced and sent to all
  Payers for whom an eligibility match was made

5
Current Notes continued

• As part of the COB record creation process, FISS
  stores the COB Trading Partner ID (s) on page 6
  of the UB92 Claim Inquiry in FISS online for
  viewing via DDE by Providers.
• A list of UGS COB Trading Partners and their IDs
  is on the www.ugsmedicare.com Website under
  Providers/EDI/Coordination of Benefits

6
Future

• The National COBC receives an Eligibility file
  from all Payers with whom the COBC (not the FI)
  has an agreement (TPA)
• The COBC validates the Eligibility data (format
  and completeness) and forwards to CWF
• The FI (UGS) receives and processes claim from
  Provider

7
Future continued

• FI sends claim to CWF for eligibility
  verification prior to payment
• As part of its new procedure, CWF not only
  completes regular Medicare eligibility process,
  but also compares data to all Payers Eligibility
  files. If match(es) is/are found, it is noted on
  response back to the FI

8
Future continued further

• Crossover claims are created by FY at time of
  payment (Remit process) and forwarded daily via
  an electronic flatfile to the COBC
• The COBC will combine all claims for a single
  Payer and translate into the HIPAA (ANSI 4010
  837) format for transmission to the respective
  Payers.

9
Future Notes

• COBC - Pilot underway
• Migration of all current Payers with TPAs during
  six month period from October 1, 2004 to March
  31, 2005.
• New Trading Partners will sign TPAs (COBAs) with
  the COBC directly and not with the FIs.

10
References

• Detailed User Guide on the new process -
• www.cms.hhs.gov/medicare/cob/pdf/coba_userguide.pd
  f
• MedlearnsMatters -
• www.cms.hhs.gov/medlearn/matters/mmarticles/2004/M
  M3218.pdf
• and
• www.cms.hhs.gov/medlearn/matters/mmarticles/2004/M
  M3109.pdf

11
Questions?