CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Coordination of Benefits (COB) reimbursement policy

Defines how Blue Cross & Blue Shield of Rhode Island (BCBSRI) coordinates payment when another payer exists and explains secondary payer payment rules affecting providers and members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoordination of Benefits (COB) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 20, 2001

Next Review DateN/A

Key ActionBill the primary payer first when BCBSRI is secondary; if BCBSRI later determines it was not primary, retract and rebill to the primary and resubmit with the primary payer's EOB.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20%Medicare secondary rate (participating)

lesser of allowanceBCBSRI secondary payment rule

multiplePublication history

Coordination of Benefits Payment Rules

Coordination of Benefits payment criteria

Covered when BCBSRI is secondary to another payer; payment follows the rules below.

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BCBSRI will provide benefit consideration only for the lesser of BCBSRI's allowance or the outstanding member liability after payment by the primary payer, not to exceed billed charges per the member's contract.

Medicare secondary rules (one of)

If BCBSRI is secondary to Medicare and the servicing provider participates in Medicare, BCBSRI will pay 20% of the rate per the Rhode Island Medicare Fee Schedule.
If BCBSRI is secondary to Medicare and the servicing provider is ineligible to participate with Medicare, BCBSRI will process the claim as if BCBSRI were the primary payer.

If BCBSRI determines after payment that it was not the primary insurer, BCBSRI may retract the claim payment; the provider should bill the primary insurer first and then resubmit the claim to BCBSRI with the primary insurer's EOB for secondary coverage.

Benefits and eligibility may vary by group or contract; refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coordination of benefits provisions, which supersede this policy.

Billing, Verification, and Authorization

Prior Authorization

Prior Authorization — No prior authorization required

No prior authorization is required for coordination of benefits when BCBSRI is the secondary payer.

Billing Rule

Billing sequence and retraction — Bill primary payer first

When Blue Cross & Blue Shield of Rhode Island (BCBSRI) is the secondary payer, providers must bill the primary payer first. BCBSRI will consider payment only for the lesser of BCBSRI's allowance or the outstanding member liability after the primary payer's payment, and not to exceed charges in accordance with the member's contract.

Bill the primary payer first before submitting to BCBSRI.
BCBSRI will pay the lesser of its allowance or the member's remaining liability after primary payment, not to exceed contract charges.

Billing Rule

Retraction and resubmission guidance

If BCBSRI pays as primary and BCBSRI later determines it was secondary, BCBSRI may retract the payment. In that event, the provider should bill the correct primary insurer and then resubmit the claim to BCBSRI with the primary insurer's EOB for secondary consideration.

BCBSRI may retract payments made in error if primary/secondary status is reversed.
After retraction: bill the primary insurer, obtain the primary EOB, then resubmit to BCBSRI for secondary payment consideration.

Billing Rule

Medicare coordination specifics

For Medicare coordination: • If BCBSRI is secondary to Original Medicare or a Medicare Advantage Organization (MAO) and the servicing provider accepts Medicare assignment, BCBSRI will pay 20% of the rate per the Rhode Island Medicare Fee Schedule (when applicable). • If BCBSRI is secondary to Medicare and the servicing provider is ineligible to participate with Medicare, BCBSRI will process the claim as if BCBSRI were the primary payer.

Note

Eligibility and benefit verification — Verify with provider call center

For member-specific benefits and eligibility, providers must verify benefits and eligibility with BCBSRI before rendering services. Benefits and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement; those documents supersede this policy. For questions about a member's benefits or eligibility, call the BCBSRI provider call center.

Verify member eligibility and benefit coverage with the provider call center prior to services when benefit-specific determinations are required.
Refer to the member's subscriber agreement, certificate, or employer agreement for definitive coverage and benefit terms.

Key Terms

Coordination of Benefits (COB)

DefinitionCoordination of Benefits (COB) is the provision used to establish the order in which health insurance plans pay claims when more than one plan exists.

Primary vs SecondaryWhen multiple plans exist, the primary payer pays first and BCBSRI will consider payment as secondary payer for any remaining member liability up to BCBSRI's allowance, not to exceed billed charges.

Claim retraction and resubmissionIf BCBSRI determines after payment that it was not the primary insurer, BCBSRI may retract its payment; the claim should then be billed to the primary insurer and resubmitted to BCBSRI with the primary insurer's EOB for secondary coverage.

BCBSRI as secondary to Medicare (participating provider)

Payment rule for participating providersIf BCBSRI is secondary to Medicare and the servicing provider participates in Medicare, BCBSRI will pay 20% of the rate per the Rhode Island Medicare Fee Schedule.

Billing sequenceProviders should bill the primary payer first; BCBSRI will consider secondary payment after primary payment is made.

Secondary payment limitBCBSRI provides benefit consideration for the lesser of BCBSRI's allowance or the outstanding member liability after payment by the primary payer, not to exceed billed charges.

BCBSRI as secondary to Medicare (non‑participating provider)

Payment processing when provider is non‑participating in MedicareIf BCBSRI is secondary to Medicare and the servicing provider is ineligible to participate with Medicare, BCBSRI will process the claim as if BCBSRI were the primary payer.

Retraction policyIf BCBSRI determines after payment that it was not the primary insurer, BCBSRI may retract payment; the claim should then be billed to the primary insurer and resubmitted to BCBSRI with the primary insurer's EOB for secondary coverage.

Effect on provider reimbursementBCBSRI will apply its usual allowance and payment rules as though BCBSRI were the primary payer when the servicing provider is not eligible to participate in Medicare.

OpenPayer

Coordination of Benefits (COB) reimbursement policy

Coordination of Benefits Payment Rules

Coding and Payment Details

Billing, Verification, and Authorization

Key Terms