When a member is injured in an auto accident or on the job, another insurer is often primary. The guidelines below will help you submit these coordination of benefit claims.
Reminder: Third-party liability claims, like other claims requiring attachments, must be mailed. Submit original claim forms. We cannot accept faxes and photocopies for processing.
| If you’re submitting a claim for a member who has related: | You can bill us for any outstanding balance after: | Be sure to: |
|---|---|---|
| Auto insurance | The auto insurer:
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| Workers’ compensation insurance | The workers’ compensation insurer has:
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* Other states’ Blue Cross Blue Shield Plans may have other Personal Injury Protection (PIP) dollar limits.
Notes:
- If a third-party or lump-sum settlement is reached prior to claim submission, claims may not be honored.
- Workers’ compensation insurers’ denials are subject to review by the Third-Party Liability Department to determine if claims will be honored.
- Exemptions from state law:
- Self-funded accounts
- Blue Cross has the right to cite exemption from state law for self-funded accounts under the Employee Retirement Income Security Act (ERISA).
- If the account is self-funded, ERISA may pre-empt state insurance law.
- The PIP insurer will not be able to rely on standard coordination of benefits.
- Self-funded accounts process secondary to all automobile PIP and MedPay coverage.
- Federal Employee Program (FEP)
- Blue Cross also has the right to cite exemption from state law for FEP members because FEP is governed under the Federal government’s Office of Personnel Management.
- The contract allows FEP to process secondary to all automobile PIP and MedPay coverage.
- If a third-party or lump-sum settlement is reached prior to claims submission, claims may not be honored.
- Self-funded accounts
If you have questions about billing claims related to other types of accidental injury (for example, dog bites or falls), please contact our Third-Party Liability Department at 1-800-444-6502.
| How to appeal a third-party liability claim involving a Massachusetts member
If we reject your claim because of an error in the claim, follow the replacement claim process. However, if your third-party liability claim involves a Massachusetts member and you disagree with the third-party liability denial, fax a Request for Claim Review Form and any required documents to our Third-Party Liability Department at 1-617-246-9967. BlueCard (out-of-state) third-party liability appeals should be mailed to the claims address for Professional or Institutional claims. |
When a member has more than one insurer covering his or her health care costs, the insurers need to coordinate payment. The primary insurer must process the claim first. The claim is then submitted to a secondary or tertiary insurer with the explanation of benefits from the primary insurer. These are often called "coordination of benefits" claims.
Dentists, please note: benefits are not coordinated for pre-treatment estimates.
Who is the primary insurer?
Before submitting a claim, determine who the primary insurer is. General rules appear below.
When the member has both dental and medical coverage through us and either policy would cover the services, our medical plan is considered primary (except for FEP members).
For married couples:
- With no Medicare, who are each covered by their own active employer group plan, each spouse is primary on their own plan and secondary on their spouse’s plan.
- With both Medicare and an active Federal Employee Program policy, FEP is primary.
For healthy newborns receiving nursery care, the mother’s plan is primary is most cases. For other dependents:
- If the parents are married or living together, the plan of parent whose birthday falls first in the calendar year is primary.
- If the married parents have the same birthday, the plan that has been in effect longer is primary
- If the parents are not married or living together:*
| The plan of: | Is: |
|---|---|
| The parent with custody | Primary |
| The spouse of the parent with custody | Secondary |
| The non-custodial parent | Tertiary |
* These provisions apply in the absence of a specific court decree assigning responsibility for the health care expenses of the child to a particular parent.
Reimbursement for coordination of benefits claims
We will pay the balance up to the amount we would have paid if we had been the primary insurer. Please note that some accounts may elect maintenance of benefits payment calculations that may result in a lesser payment.
Patient liability
Before you calculate the patient’s liability, wait until you have received all payers’ EOBs. Once all insurance payments have been made, calculate your patient’s liability by claim line rather than using the total claim payment amount.
- Dental services. You may only charge the member up to the fee schedule amount for additional services in that calendar year for services that would otherwise be covered. This change applies to all benefit limits for any services that are covered, including:
- Annual maximums (calendar year and plan year) and orthodontic lifetime maximums
- Time limits
- Frequencies.
Resources
When we are secondary to Medicare or another insurer, submit the claim to the primary insurer first. When you receive the primary insurer’s EOB, send the secondary claim according to instructions.
Refer to our billing guidelines or 837 Companion Guide for field/data requirements. Additional tips for COB claims appear below.
For claims involving workers’ compensation or auto accidents, refer to our third-party liability information.
When we are not the primary insurer
| If the primary insurer | You should | By this time |
|---|---|---|
| Paid the claim or allowed more than $0 | Submit the COB claim (see tips below) | Within one year of the date the other insurer processed the claim |
| If the primary insurer | And | You should | By this time |
|---|---|---|---|
| Denied the claim or paid/ allowed nothing | You can submit the claim to us within timely filing limits | Submit the COB claim (see tips below) | Within timely filing limits |
| The claim is beyond timely filing limits | Combine your appeal with your claim. Send the following documents to the appropriate appeals address.
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When we are primary
Follow standard claim submission guidelines for claims within timely filing limits.
| If your claim is | But | You should | By this time |
|---|---|---|---|
| No longer within our timely filing limit | You submitted a claim to another insurer within the timely filing limit and you have an EOB with their denial date |
Combine your appeal with your claim. Send the following documents to the appropriate appeals address.
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Tips for electronic COB claims
- You must report:
- The primary insurer’s name and address
- And the insured member’s ID number
- If the other insurer paid, report the amount paid by the other insurer at the claim’s line level.
- If the claim was denied by the primary insurer, report the reject reason.
Dentists:
- Do not attach Pre-Treatment Estimates when submitting your COB claim. Only EOBs are accepted.
- Please provide all required information in your claim. Including the Vyne Dental number is helpful, but not required. (Vyne Dental was formerly National Electronic Attachment, or NEA.)
Methods for submitting electronic COB claims
| If you submit electronic claims this way | Be sure to |
|---|---|
| Web-based tool | Refer to the primary claim and secondary claim instructions in the tool’s user guide |
| Clearinghouse | Confirm with your clearinghouse that COB data entered in your software is transmitted to Blue Cross |
| EDI transaction (Direct Connection) | Review the section, “Coverage Secondary to Medicare or Other Payers,” in our 837 Companion Guide |
ConnectCenter: At this time, you cannot submit 1500 claims involving coordination of benefits using the Direct Data Entry tool.
Dental Connect: We do not currently provide claim submission through Dental Connect; however, you can purchase this functionality through Change Healthcare.
Tips for paper COB claims
Be sure to:
- Enter the other insurer’s information on your claim form as required in our billing guidelines
- Mail the claim form with the other insurer’s EOB attached.
If we reject a claim because we are not primary, you must submit the claim to the primary insurer.
Medical claims
When you receive the other insurer’s explanation of benefits, submit a replacement claim. We must receive the replacement claim within one year of the date the other insurer processed the claim.
You can submit the replacement claim electronically. Be sure to follow instructions for replacement claims and Coordination of Benefits claims. If you are sending a paper claim, attach the other insurer’s EOB and mail it to the appropriate address.
| How to appeal a Massachusetts COB claim denial
If we reject your claim because we are not the primary insurer, follow the replacement claim process described above. However, if your Blue Cross Blue Shield of Massachusetts COB claim was denied for another reason and you disagree with the denial, send a Request for Claim Review Form and any required documents by: Fax: 1-617-246-5032 Or mail: Blue Cross Blue Shield of MA BlueCard (out-of-state) COB appeals should be mailed to the claims address for Professional or Institutional claims. |
Dental claims
When you receive the other insurer’s Explanation of Benefits, send us a Request for Claim Review Form and the other insurer’s EOB. Mail your documents to the address for Dental appeals:
Blue Cross Blue Shield of MA
Process Control
PO Box 986010
Boston, MA 02298
Note: We must receive the appeal within one year of the date the other insurer processed the claim or within two years from the date of service.
If you have questions about benefits or claim adjustments, please call Dental Provider Services at 1-800-882-1178, Option 3.
If a Medicare member has secondary insurance coverage through one of our plans (such as the Federal Employee Program, Medex, a group policy, or coverage through a vendor), Medicare generally forwards claims to us for processing.
Once a month, Blue Cross forwards eligibility information (the member’s Medicare MBI number and effective dates of coverage) to the Centers for Medicare & Medicaid Services. Medicare uses this information when determining which claims should be forwarded to Blue Cross.
| If: | Then: |
|---|---|
| The Medicare MBI number is missing from our eligibility file |
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| The Medicare MBI number we have on file is invalid |
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| The member is an out-of-state federal employee |
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Important:
- All paper claims must be accompanied by the corresponding Medicare explanation of benefits (EOB).
- We must receive your paper claim within one year of the Medicare EOB’s processed date.
- You must wait 30 calendar days after receiving the Medicare payment before submitting the secondary claim to Blue Cross. This is because it may take up to 30 calendar days after you receive Medicare’s payment for you to receive our payment or instructions. Medicare primary claims submitted to us within 30 calendar days of the Medicare payment date or with no Medicare payment date will be rejected.
