COB

Question 1

Definition of COB

Answer 1

when more than one party has responsibility for the claim

Question 2

NAIC guidelines for COB

Answer 2

1. Plan covering an individual as EE is primary (spouse/child secondary)
2. Birthday rule applies for children covered by 2 group plans - parent whose birthday falls first in the year is primary
3. Divorce/Custodial issues-Court order specify which parent is primary, if not, custodial parent is primary
4. COBRA continuation coverage- usually secondary

Question 3

Medicare Provisions for COB

Answer 3

1. If covered by group plan from ER >=20EE and still working- Group plan is primary, Medicare is secondary
2. If covered by group plan from ER <20EE and still working- Medicare is primary, Group plan is secondary
3. If covered by group plan as retiree - Medicare is primary and group plan is secondary

Question 4

Administrative options

Answer 4

• Pay and pursue - health plan pay claims as primary then research if another carrier should be primary; limit prompt pay issue; costly and difficult to collect funds
• Pursue and pay - health plan denies claim pending COB, send letters to member asking for COB. Once COB is recorded in system, other claims can be paid out in the same way