Coordination of Benefits (COB) and Secondary Billing Flashcards

A patient is covered by both their own employer's plan and their spouse's employer plan. The 'birthday rule' is used to determine:

Answer: Which plan is primary based on whose birthday falls earlier in the calendar year

The birthday rule states that when a patient is covered by two plans, the plan of the policyholder whose birthday (month and day) falls earlier in the calendar year is primary. Year of birth is not used unless birthdays fall on the same day.

Under Medicare Secondary Payer (MSP) rules, Medicare is the SECONDARY payer when:

Answer: The patient is actively employed and covered by an employer group health plan from an employer with 20 or more employees

MSP rules require that an employer group health plan (EGHP) from an employer with ≥20 employees pays primary when the Medicare beneficiary is actively working and covered under the EGHP. Medicare only pays secondary in that scenario.

What is 'crossover billing' in the context of coordination of benefits?

Answer: The process where Medicare automatically forwards a claim to Medicaid for beneficiaries who are dual-eligible, so the provider does not need to bill Medicaid separately

For dual-eligible patients (Medicare and Medicaid), Medicare electronically 'crosses over' the claim to Medicaid after adjudication, so the provider receives both Medicare payment and any Medicaid supplemental payment without filing a separate Medicaid claim.

When billing a secondary payer, the amount submitted should be based on:

Answer: The remaining balance after the primary payer's payment and any contractual adjustments have been applied

Secondary billing is based on the patient's remaining liability after the primary payer adjudicates the claim. The secondary payer's Explanation of Benefits (EOB/RA) from the primary must accompany the claim to show what was paid and what remains.

A COB clause in a health insurance policy is designed primarily to:

Answer: Prevent a patient from collecting more than 100% of the allowable amount for a service when covered by multiple insurance plans

Coordination of benefits rules exist to ensure that when a patient has multiple health plans, the combined payment from all payers does not exceed the total allowed amount or the provider's billed charge — preventing over-payment or patient profit.

Which of the following situations correctly identifies Medicare as the PRIMARY payer?

Answer: A Medicare beneficiary who has end-stage renal disease (ESRD) and is in the 31st month of their coordination period

For ESRD patients, the group health plan is primary for the first 30 months (the coordination period); after that period ends, Medicare becomes primary. Options B, C, and D all represent situations where Medicare is secondary under MSP rules.