Coordination of Benefits
(COB) are the rules for how insurance pays when a patient has coverage under more than one plan. There are many different ways to calculate COB, made even more complicated by various State laws. Sometimes, non-duplication means that the plan will never pay anything when they are in the secondary position.
Set Up COB Defaults
Click on Setup in the main menu, then click on Modules Preferences. The following dialog opens.
- From the TABS at the top, click on the "Family" tab.
- From within the Family Tab, to the right of 'Coordination of Benefits (COB) Rule', click on the down arrow and select the Default of Basic, Standard, or Carve Out.
- When done click on the 'OK' button.
Practice-Web has the different COB options as outlined below.
Basic
Prior to version 12.0, this was the only option.
Secondary pays the lesser of:
1. the amount that it would have paid in the absence of any other coverage.2. The secondary allowed amount minus what primary paid.
For example, on a $100 procedure, primary might pay $80 (80% of its allowed fee).
If the secondary allowed amount was $110, secondary would pay the lesser of $88 or ($110 - $80), so $30. If the secondary allowed amount was $90, secondary would pay the lesser of $72 or ($90 - $80), so $10.
Standard
Secondary pays the lesser of:
1. the amount that it would have paid in the absence of any other coverage.2. The patient's portion under the primary plan.
For example, on a $100 procedure, primary might pay $80 (80% of its allowed fee).
If the secondary allowed amount was $110, secondary would pay the lesser of $88 or $20, so $20.
If the secondary allowed amount was $90, secondary would pay the lesser of $72 or $20, so $20.
Carve Out
Secondary reduces what they will pay by what primary paid. For example, on a $100 procedure, primary might pay $80 (80% of its allowed fee).
If secondary allowed amount was $110, secondary would pay $88 - $80 = $8.
If secondary allowed amount was $90, secondary would pay $72 - $80 = $0.