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Distant Past. The FI (UGS) receives and processes claim from ProviderData on claim indicates secondary payerClaim has deductible or coinsuranceClaim is selected, formatted, and sent electronically to Payers with whom the FI (UGS) has an agreement (TPA) . Current. The FI (UGS) receives and loads
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1. COBC Coordination Of Benefits Contractor
(electronic crossover)
Randall Watkins, UGS, 10/8/04
2. Distant Past The FI (UGS) receives and processes claim from Provider
Data on claim indicates secondary payer
Claim has deductible or coinsurance
Claim is selected, formatted, and sent electronically to Payers with whom the FI (UGS) has an agreement (TPA)
3. Current The FI (UGS) receives and loads into FISS an Eligibility file from the Payers with whom the FI has an agreement (TPA)
The FI (UGS) receives and processes claim from Provider
Claim matches data on Payer’s Eligibility file and meets Payer’s selection criteria.
Claim is selected, formatted, and sent electronically to Payer.
4. Current: Notes Prior to January 1, 2004, regardless of how many Payer eligibility matches were present in the tables for a single Beneficiary, only the first match produced a claim for crossover
January 1, 2004 and after, per CMS instructions, a crossover claim was produced and sent to all Payers for whom an eligibility match was made
5. Current: Notes continued As part of the COB record creation process, FISS stores the COB Trading Partner ID (s) on page 6 of the UB92 Claim Inquiry in FISS online for viewing via DDE by Providers.
A list of UGS COB Trading Partners and their IDs is on the www.ugsmedicare.com Website under Providers/EDI/Coordination of Benefits
6. Future The National COBC receives an Eligibility file from all Payers with whom the COBC (not the FI) has an agreement (TPA)
The COBC validates the Eligibility data (format and completeness) and forwards to CWF
The FI (UGS) receives and processes claim from Provider
7. Future continued FI sends claim to CWF for eligibility verification prior to payment
As part of its new procedure, CWF not only completes regular Medicare eligibility process, but also compares data to all Payer’s Eligibility files. If match(es) is/are found, it is noted on response back to the FI
8. Future continued further Crossover claims are created by FY at time of payment (Remit process) and forwarded daily via an electronic flatfile to the COBC
The COBC will combine all claims for a single Payer and translate into the HIPAA (ANSI 4010 837) format for transmission to the respective Payers.
9. Future: Notes COBC - Pilot underway
Migration of all current Payers with TPAs during six month period from October 1, 2004 to March 31, 2005.
New Trading Partners will sign TPAs (COBAs) with the COBC directly and not with the FIs.
10. References Detailed User Guide on the new process -
www.cms.hhs.gov/medicare/cob/pdf/coba_userguide.pdf
MedlearnsMatters -
www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3218.pdf
and
www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3109.pdf
11. Questions?