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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyCareSource Georgia COB Billing Policy Update | Ope…
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    CurrentCareSource GeorgiaPolicy MCD-PY-1344

    Coordination of Benefits

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    This policy governs how CareSource Georgia coordinates payment when a member has another health plan or insurance carrier, including claim submission, reimbursement limits, timely filing, coding requirements, and disputes. It applies to providers billing CareSource as the secondary payer for covered Medicaid services.

    Policy Summary
    PayerCareSource Georgia
    PolicyCoordination of Benefits
    Policy CodePolicy MCD-PY-1344
    Change TypeNo material change
    Effective DateMar 1, 2025
    Next Review DateN/A
    Key ActionWhen CareSource is not the primary carrier, bill the primary carrier first, then submit any remaining balance to CareSource with the primary payer information and payment amount.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Secondary payerCareSource payment role when another carrier is primary
    Contracted maximumMaximum combined payment limit for contracted providers
    $0CareSource payment when primary payment meets or exceeds the maximum
    90 daysCommon deadline for submitting a primary payer EOP or COB dispute

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    4Claim adjustment group codes identified by the policy

    Secondary Payment Eligibility and COB Denials

    Secondary payment eligibility

    CareSource may consider secondary payment when ALL of the following are met:

    ALL of the following

    • The service is covered under the member's benefit plan and CareSource is the secondary payer.
    • The provider has billed the primary carrier for all services first and is submitting any remaining balance to CareSource.
    • The claim identifies the total amount billed, total amount paid by the primary carrier, and balance due, and includes a valid provider signature.
    • The claim includes information verifying the services billed and the payment received from the primary carrier.
    • The claim includes approved CPT or HCPCS codes and appropriate modifiers, when applicable.
    • The combined primary and CareSource payments do not exceed the applicable Medicaid contracted maximum allowable amount or other applicable reimbursement ceiling.

    COB denial and dispute conditions

    COB claims may be denied or re-denied when ANY of the following conditions applies:

    ANY of the following

    • The primary payer's Explanation of Payment (EOP) is missing when CareSource has identified other coverage.
    • The codes submitted on the CareSource claim do not match the codes reported on the primary payer's EOP.
    • The provider does not submit the primary payer's EOP within the original timely filing period or, when applicable, within 90 days of the primary payer's EOP date.
    • The provider does not notify CareSource within the required deadline that the primary payer's policy terminated or was not in effect on the date of service.

    Payment Limits, Deadlines, and Claim Codes

    Claim Adjustment Group CodesModifier
    COContractual Obligation
    OAOther Adjustment
    PIPayer Initiated Reductions
    PRPatient Responsibility
    Patient Responsibility Claim Adjustment Reason CodesModifier
    PR1Deductible
    PR2Coinsurance
    PR3Copayment
    Primary EOP contractual-obligation examplesModifier
    24Example code used with contractual obligation adjustment reporting
    45Example code used with contractual obligation adjustment reporting
    222Example code used with contractual obligation adjustment reporting
    P24Example code used with contractual obligation adjustment reporting
    P25Example code used with contractual obligation adjustment reporting
    26Example code used with contractual obligation adjustment reporting
    Procedure coding and modifiersmixedCovered
    CPTIndustry-standard procedure codes accepted when approved and reported consistently with the primary payer EOP
    HCPCSIndustry-standard healthcare procedure and supply codes accepted when approved and reported consistently with the primary payer EOP
    Contracted Provider COB Payment Ceiling
    ApplicabilityContracted providers when CareSource coordinates benefits with the primary carrier.
    Payment calculationCareSource reimbursement is based on the Medicaid contracted maximum allowable amount minus any payment made by the primary carrier.
    Combined payment ceilingThe primary carrier payment plus the CareSource payment must not exceed the Medicaid contracted maximum allowable amount.
    Zero-Payment Threshold
    TriggerThe other carrier’s reimbursement is equal to or greater than the Medicaid contracted maximum allowable amount.

    Secondary Billing and COB Submission Steps

    Billing Rule

    Bill the Primary Carrier First

    If CareSource is not the primary carrier, bill the primary carrier for all services before submitting the claim to CareSource. Submit any balance remaining after the primary payer's payment to CareSource for consideration.

    • Bill the primary carrier first when other primary coverage exists.
    • Submit the remaining balance to CareSource after receiving the primary payment.
    Documentation Required

    Document Primary Payment on the Claim

    The claim submitted to CareSource must document the primary payer's payment and the amount remaining for consideration, with a valid provider signature and information verifying the services billed.

    Key Coordination of Benefits Terms

    CareSource Provider Agreement
    DefinitionThe contract between the provider and CareSource for the provision of services to individuals enrolled with the plan.
    Covered agreementsThe term includes, but is not limited to, contracts titled Provider Agreement and Group Practice Services Agreement.
    PartiesThe agreement is between the provider and CareSource.
    Coordination of Benefits (COB)
    DefinitionThe process of determining which health plan or insurance policy will pay first.
    Payment obligationsCOB determines the payment obligations of each health plan, medical insurance policy, or third-party resource.
    Policy Summary
    PayerCareSource Georgia
    PolicyCoordination of Benefits
    Policy CodePolicy MCD-PY-1344
    Change TypeNo material change
    Effective DateMar 1, 2025
    Next Review DateN/A
    Key ActionWhen CareSource is not the primary carrier, bill the primary carrier first, then submit any remaining balance to CareSource with the primary payer information and payment amount.
    SourceLink
    On This Page
    Secondary Payment Eligibility and COB DenialsPayment Limits, Deadlines, and Claim CodesSecondary Billing and COB Submission StepsKey Coordination of Benefits Terms
    CareSource payment
    CareSource pays $0 for the item or service.
    Claim statusA claim that pays at zero is considered a paid claim, not a denied claim.
    Non-Contracted Provider COB Payment Ceiling
    ApplicabilityNon-contracted providers when the other insurance carrier’s payment is less than the CareSource Medicaid non-participating reimbursement rate.
    Payment limitThe sum of the other carrier’s payment and CareSource’s payment must not exceed the CareSource Medicaid non-participating reimbursement rate.
    Reimbursement basisThe CareSource Medicaid non-participating reimbursement rate is the applicable combined-payment ceiling.
    EOP or COB Dispute Submission Period
    Primary payer EOPSubmit the primary payer’s EOP with the CareSource claim within the claims timely filing period when the provider knows the member has primary coverage.
    EOP after denialIf the initial timely filing period has elapsed, submit the EOP within 90 days of the primary payer’s EOP date.
    Coverage disputeNotify CareSource of a dispute within the original timely filing period or within 90 days of the applicable EOP, denial, or actual receipt date, as specified by the policy.
    Automatic COB Adjustment Period
    Qualifying informationRetroactive or updated coverage information must be received by CareSource in connection with a denied COB claim.
    Adjustment periodDenied COB claims are automatically adjusted when the updated coverage information is received within 90 days from the denial for COB information.
    After 90 daysIf updated coverage information is received after 90 days from the denial, the provider must request claim adjustment within the original timely filing period or within 90 days from the EOP denial date, whichever is greater.
    • Include the total amount billed.
    • Include the total amount paid by the primary carrier.
    • Include the balance due after primary payment.
    • Include a valid provider signature and related claim information verifying the services and primary payment.
    Billing Rule

    Submit the Primary Payer EOP

    When primary coverage is known, submit the primary payer's explanation of payment (EOP) with the claim to CareSource within the applicable claims timely filing period. Missing EOP documentation may result in a COB-information denial.

    • Submit the primary payer's EOP with the CareSource claim.
    • If CareSource requests the EOP after the initial timely filing period has elapsed, submit it within 90 days of the primary payer's EOP date.
    • A claim submitted without the required EOP may be denied for missing COB information.
    Denial Risk

    Respond to COB Denials and Disputes

    Respond promptly to COB denials or disputes involving terminated or inactive primary coverage. Notify CareSource and submit the requested EOP or dispute information by the applicable deadline to avoid a re-denial for untimely filing.

    • For a dispute about primary coverage being terminated or not in effect on the date of service, notify CareSource within the original timely filing period or within 90 days of the applicable primary EOP, denial, or receipt date, whichever is greater as specified by the applicable rule.
    • If a COB denial occurs, submit the primary payer's EOP within 90 days of the EOP date when the initial timely filing period has elapsed.
    • If updated coverage information is received more than 90 days after a COB denial, request claim adjustment within the original timely filing period or within 90 days of the EOP denial date, whichever is greater.
    • Failure to submit the dispute or EOP within the applicable deadline may cause the claim to re-deny as untimely filed.
    Denial Risk

    Match Claim Codes to the Primary EOP

    File the CareSource claim using the same codes that the primary payer reported on the EOP. CareSource may deny the claim when the codes on the received claim do not match the primary payer's EOP.

    • Match the submitted claim codes to the primary payer's EOP.
    • Review CPT, HCPCS, and applicable adjustment coding for consistency with the primary EOP.
    • A mismatch between the claim and the primary payer's EOP creates denial risk.
    Billing Rule

    Use Approved Procedure Codes and Modifiers

    Reimbursement depends on submitting approved CPT and HCPCS procedure codes with appropriate modifiers when applicable. Refer to the individual fee schedule for the appropriate codes.

    • Use approved CPT and HCPCS procedure codes.
    • Include appropriate modifiers when applicable.
    • Confirm code requirements against the individual fee schedule.
    Multiple sourcesIt applies when two or more health plans, insurance policies, or third-party resources cover the same benefits for CareSource members.
    Explanation of Payment (EOP)
    DefinitionA detailed explanation of payment or denial of a claim issued by an insurance carrier.
    Payment informationThe EOP explains an insurance carrier’s payment of a claim.
    Denial informationThe EOP also explains an insurance carrier’s denial of a claim.
    Primary Carrier
    DefinitionThe insurance carrier that has been determined to be responsible for primary payment.
    Payment orderThe Primary Carrier is responsible for payment before the secondary carrier.
    DeterminationPrimary carrier status is determined under the applicable coordination-of-benefits process.