Coordination of Benefits Contractor (COBC)
CMS recently implemented a uniform national contract, called the Coordination of Benefits Agreement (COBA), to negotiate and implement crossover Trading Partner Agreements (TPAs) with supplement payers/insurers. Under this agreement, a central contractor, the Coordination of Benefits Contractor (COBC), will automatically route eligibility-based files to other insurers that pay after Medicare has made its payment decision on a claim. This consolidation alleviates the need for supplemental payers/insurers to have to sign multiple crossover agreements with individual Medicare Contractors for the purposes of sending and receiving Medicare paid claims information. In addition, they will no longer need to send separate eligibility files to or receive separate claims crossover files from individual Medicare Contractors. For more information regarding this service, please visit the CMS website.
Do any Medicare contractors cross over claims directly to supplemental payers/insurers?
No, CMS implemented the COBA which states that the COBC will forward all claims crossovers to the supplemental payers. Government Health Incorporated (GHI) is the COBC selected by CMS.
How are claims crossed over?
An eligibility file is sent from the Trading Partner (secondary insurance company) to the COBC. The file contains data to identify the Health Insurance Claims Numbers (HICN) and claims criteria, specified by the Trading Partner, for crossovers. Each Trading Partner is issued a COBA ID. The COBA ID and eligibility file data, along with information specific to that trading partner, are stored in Medicare's Common Working File (CWF). When claims are processed, CWF compares each Coordination of Benefits (COB) Trading Partner's claims selection criteria against the Medicare claims. If the claim matches the Trading Partner's claims criteria and HICN in their eligibility file, the claim information is automatically forwarded to the Trading Partner, via an electronic file.
If the HICN on a claim received in the Medicare System is not on the Trading Partner's file, will the claim be crossed over?
No, claims with the HICN not on the Trading Partner's eligibility file will not be crossed over. Also, the claim information must match the claim criteria specified by the Trading Partner in the eligibility file.
How can providers tell if a claim has crossed over?
The payment section, on page six of the Fiscal Intermediary Standard System (FISS), contains a "CROSSOVER IND" field. This field will either be blank or have a value of 1 in it. If it is blank, the claim did not cross over. If it contains a "1", the claim did cross over to the Trading Partner in the field titled "PARTNER ID". The Trading Partner ID is a nine-digit ID assigned by COBC. For providers who receive a Standard Paper Remittance (SPR) the crossover information can be found under the "CLM STATUS" field. The crossover information can also be found on the ANSI 835 Electronic Remittance Advice in the "TRANSFER TO (COB)" field. The Trading Partner's ID will be located in the "ID CODE" field on the ERA. If the claim crossed over to multiple Trading Partners, only the first one will be listed on the ERA.
If a claim crosses over to multiple secondaries, who gets paid first?
The claims will be crossed over simultaneously, but who gets paid first is the predetermined by the secondary/tertiary payers.
Whom do I contact if FISS shows that a claim crossed over and the supplemental insurance company has not received it?
Medicare forwards indentified crossover claims to the COBC, who in turn sends them on to the trading partner. You will need to contact the Trading Partner so they may investigate the situation to confirm if it is an internal issue or an issue with the COBC. The Trading Partner ID can be found in the payment section of page six in FISS or under the "ID CODE" field on the ERA. The Trading Partner contact information can be accessed on the CMS website.
Can I contact the COBC office directly?
The COBC should only be contacted by the Trading Partner they have the Coordination of Benefits Agreement with.
If supplemental insurer information is not on the claim, will it still crossover?
Yes. Many COBC Trading Partners secondary insurance companies submit an eligibility file to the COBC. The file contains data to indentify the claims for cross over. Medicare's CWF includes the eligibility file details that pertain to the COBC trading partner. As Medicare claims are processed, CWF applies each COB Trading Partner's claims selection criteria against the Medicare claim. The COBA ID of the trading partner and their eligibility file data are stored in CWF.
How am I notified if a situation arises that prevents Medicare from crossing over a claim that is on the eligibility file?
The COBC Detailed Error Report, listing the claims that did not cross over to the supplemental insurer, will be issued to the provider. The physician, provider, or supplier on the report will need to take appropriate action to obtain payment from the supplemental payer/insurer.