Coordination of Benefits
Policy Number: GP-X-009
Last Updated: May 24, 2022
The Coordination of Benefits (COB) provision is designed to prevent duplicate benefit payments when a patient is covered by two or more health and/or dental insurance plans. If Blue Cross and Blue Shield of Nebraska (BCBSNE) is the secondary plan, the primary insurance payer must process the claim, even if you do not contract with other insurance payer(s).
See chart below.
| Primary | Secondary | Include | Result |
|---|---|---|---|
| BCBSNE or another Blue plan | Non-Blue plan | Other carrier’s name and address on the claim filed to BCBSNE | To avoid claim processing and payment delays, include the other insurance information. This will also avoid post-payment adjustments, which can increase your administrative costs. |
| Non-Blue plan | BCBSNE or another Blue plan | Copy of the Explanation of Benefits (EOB) from the primary carrier submitted with the claim to BCBSNE | Please include the primary carrier’s EOB to avoid claim denial and post-payment adjustment. |
| More than one Blue plan | File a claim for the primary plan first; once the primary Blue plan claim is processed, file a claim for the secondary Blue plan with a copy of the primary EOB | Filing to the incorrect Blue plan as primary and/or not including the primary EOB for the secondary claim will result in delay of claim processing and post-payment adjustment. | |
COB rules dictate which payer is primary. When BCBSNE is the primary payer, benefits are determined as if no other plan provided coverage. When BCBSNE is the secondary payer, benefits are determined after the primary plan has decided its benefit amount. As the secondary payer, BCBSNE may reduce benefits due to the primary plan benefit responsibility.
Payment will not be made for any amount for which the covered person is contractually held harmless by either the primary or secondary plan. Payment shall not exceed the amount paid under the BCBSNE plan, had it been primary.
BCBSNE, along with most group health plans, follows the most current National Association Insurance Commissioners (NAIC) COB model regulations when determining the order of benefits. The NAIC COB model regulations dealing with “Order of Benefits Determination” sets six rules for determining the order of benefits between plans which can be found here MDL-120 (naic.org).
Most plans follow the “birthday rule” to determine which parent’s plan is primary for children. The plan covering the parent whose birthday falls earlier in the year is considered the primary payer.
“Birthday” refers only to the month and day in the calendar year – not the year of birth. If the parents share the same birthday, the primary plan is the plan that has been in effect for the longest time.
There are exceptions in the case of separated/divorced parent. Unless specifically stated in the decree, the primary plan is determined in the following order:
- The plan covering the custodial parent;
- The plan covering the custodial parent’s spouse;
- The plan covering the non-custodial parent; or lastly
- The plan covering the non-custodial parent’s spouse.
However, if we are informed that a divorce decree or a child support order requires one parent to be responsible for health care expenses, that parent’s plan will be primary.
A universal COB questionnaire is available on our website. Please ensure the form is completed and signed by the member.
For questions regarding other COB rules, please contact the BCBSNE Coordination of Benefits department at 402-390-1840 or 800-462-2924.
COB and Medicare
For questions about coordinating benefits with Medicare, please visit the Medicare website.
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