• Company Information

what is coordination of benefits bcbs

  • Network Participation
  • How to Join Our Networks
  • Update Your Information
  • Change of Ownership
  • Claims and Eligibility
  • BlueCard Program
  • Electronic Commerce
  • Eligibility and Benefits
  • Prior Authorization Services For Fully Insured and ASO
  • Prior Authorizations Lists for Blue Cross Medicare Advantage (PPO) and Blue Cross Medicare Advantage (HMO)
  • Prior Authorizations Lists for Designated Groups
  • Recommended Clinical Review Option
  • Prior Authorization Exemptions (Texas House Bill 3459)
  • Claims Filing Tips
  • Claim Status
  • Claim Review Process
  • Interactive Voice Response (IVR) System
  • Medicare Advantage Private Fee-for-Service (PFFS)
  • Eligibility and Benefits Inquiry (HIPAA 270/271)

Education and Reference

  • Education and Reference Center
  • 2024 Blue Review
  • Identification Cards
  • 2024 News and Updates
  • 2023 News and Updates
  • Provider Tools
  • Provider Training
  • Blue Review Archive
  • Fraud and Abuse
  • Clinical Resources
  • Behavioral Health Care Management Program
  • Clinical Practice Guidelines
  • Quality Care – Partner With Your Patients
  • eviCore Prior Authorization Program
  • Special Beginnings - Maternity Program
  • Preventive Care Guidelines/Patient Wellness Guidelines
  • Quality Improvement Tip Sheet
  • Telemedicine and Telehealth Services
  • Health Equity and Social Determinants of Health (SDoH)
  • Pharmacy Program
  • Dispensing (Quantity vs. Time) Limits
  • Medicare Part D Pharmacy Updates
  • Prescription Drug List and Prescribing Guidelines
  • Specialty Pharmacy Programs
  • Prior Authorization and Step Therapy Programs
  • Split Fill Program
  • Standards and Requirements
  • Affordable Care Act (ACA)
  • Clinical Payment and Coding Policies
  • Consolidated Appropriations Act and Transparency in Coverage Final Rule
  • 2024 Disclosure Notices
  • Federal Employee Program (FEP)
  • General Reimbursement Information
  • Medical Policies
  • Medical Policy and Pre-certification/Pre-authorization Information for Out-of-Area Members
  • Physician Efficiency, Appropriateness, & Quality (PEAQ) Program

Coordination of Benefits and Patient Share

Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits.

This article is meant to assist physicians and other professional providers, and facilities in understanding the coordination of benefits clause from the contracting perspective.

The information contained in this article applies to member's health benefit policies issued by Blue Cross and Blue Shield of Texas (BCBSTX). Please note, some Administrative Services Only (self-funded) groups may elect not to follow the general Coordination of Benefit rules of BCBSTX.

When the member's health benefit policy is issued by another Blues plan, also known as the HOME plan, the Coordination of Benefit provision is administered by that HOME plan, not BCBSTX. Therefore, the member's HOME plan health benefit policy will control how Coordination of Benefits is applied for that member.

Per the BCBSTX coordination of benefits contract language, the physicians and other professional providers, and facilities have agreed to accept the BCBSTX allowable amount (as defined by the contract) less any amount paid by the primary insurance carrier.

What does this mean for you?

Once the claim has been processed by BCBSTX as the secondary carrier, the only patient share amount that may be collected from the member is the amount showing on the BCBSTX Provider Claim Summary.

The primary carrier does not take into account the member's secondary coverage. This means that once the claim is processed as secondary by BCBSTX, any patient share amount shown to be owed on the primary carrier's explanation of benefits is no longer collectible.

If you have questions regarding a specific claim, please contact Provider Customer Service at 1-800-451-0287 to speak with a Customer Advocate.

An official website of the United States government

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

CMS Newsroom

Search cms.gov.

  • Physician Fee Schedule
  • Local Coverage Determination
  • Medically Unlikely Edits

Coordination of Benefits

Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).  

The COB Process:

  • Ensures claims are paid correctly by identifying the health benefits available to a Medicare beneficiary, coordinating the payment process, and ensuring that the primary payer, whether Medicare or other insurance, pays first.
  • Shares Medicare eligibility data with other payers and transmits Medicare-paid claims to supplemental insurers for secondary payment. Note: An agreement must be in place between the Benefits Coordination & Recovery Center (BCRC) and private insurance companies for the BCRC to automatically cross over claims. In the absence of an agreement, the person with Medicare is required to coordinate secondary or supplemental payment of benefits with any other insurers he or she may have in addition to Medicare.
  • Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments.
  • Accommodates all of the coordination needs of the Part D benefit. The COB process provides the True Out of Pocket (TrOOP) Facilitation Contractor and Part D Plans with the secondary, non-Medicare prescription drug coverage that it must have to facilitate payer determinations and the accurate calculation of the TrOOP expenses of beneficiaries; and allowing employers to easily participate in the Retire Drug Subsidy (RDS) program. Please click the Coordinating Prescription Drug Benefits link for additional information.

COB Data Sources

COB relies on many databases maintained by multiple stakeholders including federal and state programs, plans that offer health insurance and/or prescription coverage, pharmacy networks, and a variety of assistance programs available for special situations or conditions. Some of the methods used to obtain COB information are listed below:

Voluntary Data Sharing Agreements (VDSAs) - CMS has entered into VDSAs with numerous large employers. These agreements allow employers and CMS to send and receive group health plan enrollment information electronically. Where discrepancies occur in the VDSAs, employers can provide enrollment/disenrollment documentation. The VDSA data exchange process has been revised to include Part D information, enabling VDSA partners to submit records with prescription drug coverage be it primary or secondary to Part D. Employers with VDSAs can use the VDSA to submit their retiree prescription drug coverage population which supports the CMS mission of a single point of contact for entities coordinating with Medicare. Please click the Voluntary Data Sharing Agreements link for additional information.

COB Agreement (COBA) Program - CMS consolidates the Medicare paid claim crossover process through the COBA program. The COBA program established a national standard contract between the BCRC and other health insurance organizations for transmitting enrollee eligibility data and Medicare paid claims data. This means that Medigap plans, Part D plans, employer supplemental plans, self-insured plans, the Department of Defense, title XIX state Medicaid agencies, and others rely on a national repository of information with unique identifiers to receive Medicare paid claims data for the purpose of calculating their secondary payment. The COBA data exchange processes have been revised to include prescription drug coverage.

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) – This law added mandatory reporting requirements for Group Health Plan (GHP) arrangements and for liability insurance, including self-insurance, no-fault insurance, and workers' compensation. Insurers are legally required to provide information.

Other Data Exchanges - CMS has developed data exchanges for entities that have not coordinated benefits with Medicare before, including Pharmaceutical Benefit Managers (PBMs), State Pharmaceutical Assistance Programs (SPAPs), and other prescription drug payers. CMS has worked with these new partners to educate them about coordination needs, to inform CMS about how the prescription drug benefit world works today, and to develop data exchanges that allow all parties to efficiently serve our mutual customer, the beneficiary.

COB Entities

Benefits Coordination & Recovery Center (BCRC) - The BCRC consolidates the activities that support the collection, management, and reporting of other insurance coverage for beneficiaries. The BCRC takes actions to identify the health benefits available to a beneficiary and coordinates the payment process to prevent mistaken payment of Medicare benefits. The BCRC does not process claims, nor does it handle any GHP related mistaken payment recoveries or claims specific inquiries. The Medicare Administrative Contractors (MACs), Intermediaries and Carriers are responsible for processing claims submitted for primary or secondary payment.

The BCRC is responsible for the following activities:

  • Initiating an investigation when it learns that a person has other insurance. The investigation determines whether Medicare or the other insurance has primary responsibility for meeting the beneficiary's health care costs.
  • Collecting information on Employer Group Health Plans and non-group health plans (liability insurance (including self-insurance), no-fault insurance and workers’ compensation), and updating this information on Medicare databases every time a change is made to insurance coverage. Information comes from these sources:  beneficiary, doctor/provider of service, employer, GHP, liability, no-fault and workers’ compensation entity, and attorney.
  • Establishing MSP occurrence records on CWF to keep Medicare from paying when another party should pay first. The CWF is a single data source for fiscal intermediaries and carriers to verify beneficiary eligibility and conduct prepayment review and approval of claims from a national perspective. It is the only place in the fee for service claims processing system where full individual beneficiary information is housed.
  • Transmitting other health insurance data to the Medicare Beneficiary Database (MBD) for the proper coordination of Rx benefits.
  • Recovery of Non-Group Health Plan (NGHP) related mistaken payments where the beneficiary must repay Medicare. Please see the Non-Group Health Plan Recovery page for additional information.

Once the BCRC has completed its initial MSP development activities, it will notify the Commercial Repayment Center (CRC) regarding GHP MSP occurrences and NGHP MSP occurrences where a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity is the identified debtor. The BCRC will maintain responsibility for NGHP MSP occurrences where Medicare is seeking reimbursement from the beneficiary.   

When to contact the BCRC:

  • To report employment changes, or any other insurance coverage information.
  • To report a liability, auto/no-fault, or workers’ compensation case.
  • To ask a general MSP question.
  • To ask a question regarding the MSP letters and questionnaires (i.e. Secondary Claim Development (SCD) questionnaire.) For more information, click the Reporting Other Health Insurance link.

Please see the Contacts page for the BCRC’s telephone numbers and mailing address information.

Commercial Repayment Center (CRC) – The CRC is responsible for all the functions and workloads related to GHP MSP recovery with the exception of provider, physician, or other supplier recovery. The CRC is responsible for identifying and recovering Medicare mistaken payments where a GHP has primary payment responsibility. Some of these responsibilities include: issuing a Primary Payment Notice (PPN) to verify MSP information, issuing recovery demand letters when mistaken primary payments are identified, receiving payments, resolving outstanding debts, and referring delinquent debt to the Department of Treasury for further collection actions, including the Treasury Offset Program, as appropriate. Please see the Group Health Plan Recovery page for additional information.

The CRC will also perform NGHP recovery where a liability insurer (including a self-insured entity), no-fault insurer or workers’ compensation entity is the identified debtor. Please see the Non-Group Health Plan Recovery page for additional information.

Medicare Administrative Contractors (MACs) – A/B MACs and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are responsible for processing Medicare Fee-For-Service claims submitted for primary or secondary payment. These entities help ensure that claims are paid correctly when Medicare is the secondary payer. They use information on the claim form, electronic or hardcopy, and in the CMS data systems to avoid making primary payments in error. Where CMS systems indicate that other insurance is primary to Medicare, Medicare will not pay the claim as a primary payer and will deny the claim and advise the provider of service to bill the proper party.

Horizon Blue Cross Blue Shield of New Jersey

  • BACK back to www.horizonblue.com
  • COVID-19 Information
  • Update: Coverage and Reimbursement for COVID-19 Testing to change Update: Coverage and Reimbursement for COVID-19 Testing to change
  • Important Information for New COVID-19 Vaccine Claims Important Information for New COVID-19 Vaccine Claims
  • Code Terminations as the PHE Ends Code Terminations as the PHE Ends
  • PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members PHE Update: Prescription Limitation Change for Braven Health, HMO D-SNP and Medicare Part D members
  • Important Update: Additional Policy Changes as PHE Ends Important Update: Additional Policy Changes as PHE Ends
  • Some Benefits Changes as the PHE Ends Some Benefits Changes as the PHE Ends
  • Referral Requirements for All Services Referral Requirements for All Services
  • Referral Requirements for Services Not Related to COVID-19 Referral Requirements for Services Not Related to COVID-19
  • Reminder: Select one method for COVID-19 and Influenza Testing Reminder: Select one method for COVID-19 and Influenza Testing
  • Antibody testing: FDA and CDC do not recommend use to determine immunity Antibody testing: FDA and CDC do not recommend use to determine immunity
  • COVID-19 vaccine administration reimbursement at UCCs COVID-19 vaccine administration reimbursement at UCCs
  • Coverage for antibody infusion therapy Coverage for antibody infusion therapy
  • Reminder to use specific codes when evaluating for COVID-19 Reminder to use specific codes when evaluating for COVID-19
  • COVID-19 Update: Telemedicine Reimbursement Policy Addenda COVID-19 Update: Telemedicine Reimbursement Policy Addenda
  • FIND A DOCTOR
  • MEMBER SIGN IN
  • SHOP FOR A PLAN
  • Our Commitment Our Commitment

Join Our Networks

  • Ancillary Providers Ancillary Providers
  • Doula Services Practitioners
  • Doula Credentialing Application Checklist Doula Credentialing Application Checklist
  • Physicians and Other Healthcare Professionals
  • Online Enrollment Tool Online Enrollment Tool
  • Credentialing Checklist Applications Credentialing Checklist Applications
  • Join the Horizon Dental Network Join the Horizon Dental Network
  • Our Healthcare Facilities Our Healthcare Facilities
  • Products & Programs
  • Braven Health℠
  • Braven Health Supportive Program Braven Health Supportive Program
  • Braven Health℠ Drug Formulary Braven Health℠ Drug Formulary
  • Horizon Behavioral Health℠
  • Integrated System of Care (ISC) Program Integrated System of Care (ISC) Program
  • Peer Support Program Peer Support Program

Horizon Network and Product Information

  • BlueCard Program
  • BlueCard Claims BlueCard Claims
  • BlueCard Medical Policy/Pre-Certification Info BlueCard Medical Policy/Pre-Certification Info
  • BlueCard Program FAQs BlueCard Program FAQs
  • BlueCard Program Overview BlueCard Program Overview
  • BlueCard Program Tutorial BlueCard Program Tutorial
  • GeoBlue: International Coverage GeoBlue: International Coverage
  • How to Identify BlueCard Members How to Identify BlueCard Members
  • Dental Services Dental Services
  • Managed Care Plans Managed Care Plans
  • PPO and Indemnity Products PPO and Indemnity Products
  • OMNIA Health Plans OMNIA Health Plans
  • NJ SHBP/SEHBP Benefit Plans NJ SHBP/SEHBP Benefit Plans
  • Braven Health℠ Medicare Advantage Plans Braven Health℠ Medicare Advantage Plans
  • Our Pledge Our Pledge
  • Patient Care Support Patient Care Support
  • Medical Injectables Program
  • Medical Injectables Program Code Lists
  • Injectable Medication Codes Subject to MRxM Claim Review/Editing Injectable Medication Codes Subject to MRxM Claim Review/Editing
  • Injectable Medications subject to Medical Necessity and Appropriateness Review Injectable Medications subject to Medical Necessity and Appropriateness Review
  • Medical Injectables Program Provider Questions and Answers Medical Injectables Program Provider Questions and Answers
  • Pharmacy Programs
  • E-Prescribing & Incentives E-Prescribing & Incentives
  • Medicare Part D Medicare Part D
  • Pharmacy Guidelines
  • Medical Necessity Determination Policy For Prescription Drugs Medical Necessity Determination Policy For Prescription Drugs
  • Oral Anticancer Medication Coverage Law Oral Anticancer Medication Coverage Law
  • Pharmaceutical Prior Authorization Policy Pharmaceutical Prior Authorization Policy
  • Prescription Drug Formulary Exception, Tier Exception, And Multisource Brand Name Criteria Policy Prescription Drug Formulary Exception, Tier Exception, And Multisource Brand Name Criteria Policy
  • Preferred Medical Drugs Preferred Medical Drugs
  • Site of Administration Program for Infusion/Injectable Medications
  • Site of Administration Program Code List Site of Administration Program Code List
  • Specialty Pharmaceuticals for Office Administration Specialty Pharmaceuticals for Office Administration

Risk Adjustment Overview

  • Commercial Risk Adjustment (CRA) ICD-10-CM Clinical Documentation Improvement for Chronic Conditions Commercial Risk Adjustment (CRA) ICD-10-CM Clinical Documentation Improvement for Chronic Conditions
  • How Risk Adjustment Benefits You and Your Patients How Risk Adjustment Benefits You and Your Patients
  • Risk Adjustment Documentation & Coding Improvement Reference Information Risk Adjustment Documentation & Coding Improvement Reference Information
  • Risk Adjustment In Depth Risk Adjustment In Depth

Utilization Management Programs

  • Carelon Medical Benefits Management
  • Cardiovascular Program Cardiovascular Program
  • Diagnostic Imaging Program Diagnostic Imaging Program
  • Musculoskeletal Program Musculoskeletal Program
  • Oncology Program
  • Oncology Program Code List Oncology Program Code List
  • Sleep Disorder Management Program Sleep Disorder Management Program
  • Horizon Care@Home
  • About Horizon Care@Home About Horizon Care@Home
  • Find A Provider Find A Provider
  • Home Infusion Therapy Home Infusion Therapy
  • Prior Authorization/Pre-Service Registration Prior Authorization/Pre-Service Registration
  • Horizon Supportive Care and Readmission Program Horizon Supportive Care and Readmission Program
  • Surgical and Implantable Device Management Program
  • About the Surgical and Implantable Device Management Program About the Surgical and Implantable Device Management Program
  • Cardiac Services
  • Cardiac Services Procedure Codes Cardiac Services Procedure Codes
  • Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021 Surgical and Implantable Device Management Program for Cardiac Surgeries Frequently Asked Questions Updated: March 25, 2021
  • Orthopedic Services
  • Orthopedic Services Procedure Codes Orthopedic Services Procedure Codes
  • Safety and Quality Award Program Q&A Safety and Quality Award Program Q&A
  • Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions Surgical and Implantable Device Management Program Orthopedic Services Frequently Asked Questions
  • Spine Services
  • Spine Procedure Codes Spine Procedure Codes
  • TurningPoint Safety and Quality Award Program TurningPoint Safety and Quality Award Program
  • Medical Policy Criteria and Guidelines Medical Policy Criteria and Guidelines
  • PA/MND Process PA/MND Process
  • Using Out-of-Network Providers in Surgical Services Using Out-of-Network Providers in Surgical Services
  • eviCore HealthCare
  • Cardiology Imaging Program
  • Cardiology Imaging Program Provider Questions and Answers Cardiology Imaging Program Provider Questions and Answers
  • Molecular and Genomic Testing Program
  • Medical Information Requirements for Programs Administered by eviCore Medical Information Requirements for Programs Administered by eviCore
  • Medical Necessity Determination (MND) Review of Molecular and Genomic Diagnostic Testing Services Frequently Asked Questions Medical Necessity Determination (MND) Review of Molecular and Genomic Diagnostic Testing Services Frequently Asked Questions
  • Molecular and Genomic Testing Procedure Codes Molecular and Genomic Testing Procedure Codes
  • Musculoskeletal Program for Pain Management Services Musculoskeletal Program for Pain Management Services
  • Radiation Therapy Program
  • Radiation Therapy Program Questions and Answers Radiation Therapy Program Questions and Answers
  • Radiology/Imaging Services
  • 72 Hour Rule 72 Hour Rule
  • Appropriate Use of Modifier 26 Appropriate Use of Modifier 26
  • Cardiology & Radiology Imaging Procedure Codes Cardiology & Radiology Imaging Procedure Codes
  • Contrast Agents and Radiopharmaceuticals
  • Contrast Agents and Radiopharmaceuticals Contrast Agents and Radiopharmaceuticals
  • Codes Considered Inclusive to an Imaging Service Codes Considered Inclusive to an Imaging Service
  • Codes are Active/Invoice is Required Codes are Active/Invoice is Required
  • Maternal Fetal Medicine Evaluation Coding Maternal Fetal Medicine Evaluation Coding
  • Radiology/Imaging Guidelines for Emergency Room Preliminary Reads (Wet Reads) Radiology/Imaging Guidelines for Emergency Room Preliminary Reads (Wet Reads)
  • Radiology/Imaging Program Guidelines for Use of Modifier 59 Radiology/Imaging Program Guidelines for Use of Modifier 59
  • Radiology Imaging Program Q & A Radiology Imaging Program Q & A
  • Correct Coding Rules Bank for Radiology, Cardiology and Ultrasound Services
  • Correct Coding Rules Bank Correct Coding Rules Bank
  • Code Pairs Added to this List Effective January 1, 2023 Code Pairs Added to this List Effective January 1, 2023
  • Code Pairs Removed from this List Effective December 31, 2022 Code Pairs Removed from this List Effective December 31, 2022
  • Code Description Changes Code Description Changes
  • Code Bundling Rules
  • Code Bundling Rules for Radiology, Cardiology and Ultrasound Services Code Bundling Rules for Radiology, Cardiology and Ultrasound Services
  • Code Bundling Rules for PET/MRI Services Code Bundling Rules for PET/MRI Services

Value-Based Programs

  • Quality vs. Fee for Service Quality vs. Fee for Service
  • Policies & Procedures

HEDIS Resources

  • Behavioral Health HEDIS Webinar Series
  • Introduction to Behavioral Health HEDIS Introduction to Behavioral Health HEDIS
  • Child Behavioral Health HEDIS Measures Child Behavioral Health HEDIS Measures
  • Adult Behavioral Health HEDIS Measures Adult Behavioral Health HEDIS Measures
  • Substance Use Disorder HEDIS Measures Substance Use Disorder HEDIS Measures
  • Follow-Up Care for Children Prescribed ADHD Medication & Metabolic Monitoring for Children and Adolescents on Antipsychotics HEDIS Measures Follow-Up Care for Children Prescribed ADHD Medication & Metabolic Monitoring for Children and Adolescents on Antipsychotics HEDIS Measures
  • Claim Submission & Billing
  • Billable Service Exceptions
  • Eligible Laboratory Procedures Rendered by a Practice Eligible Laboratory Procedures Rendered by a Practice
  • PCP Billable Lists PCP Billable Lists
  • Claim Editing Policies Claim Editing Policies
  • Claim Overpayments Claim Overpayments
  • Claim Reimbursement Claim Reimbursement
  • Claim Submission
  • Claim Submission Instructions
  • Institutional Institutional
  • Professional Professional
  • Tips for Electronic Claim Submission Tips for Electronic Claim Submission
  • Electronic Claim Adjustments Electronic Claim Adjustments
  • Explanation of Payment Explanation of Payment
  • Pre-payment Correct Coding Reviews
  • Clinical Auditing and Monitoring Unit (CAMU) Medical Necessity Audit FAQs Clinical Auditing and Monitoring Unit (CAMU) Medical Necessity Audit FAQs
  • Provider Guidelines for Submitting Information to Our Clinical Inquiry Team Provider Guidelines for Submitting Information to Our Clinical Inquiry Team
  • Prompt Pay Guidelines Prompt Pay Guidelines

Demographic Updates

  • The Importance of Demographic Updates The Importance of Demographic Updates
  • Provider Directory Management Policy Provider Directory Management Policy
  • CMS Audits to Validate Directory Information CMS Audits to Validate Directory Information
  • How to Make Demographic Updates: Participating Ancillary Providers
  • Horizon Data Submission Template for Ancillary Providers Horizon Data Submission Template for Ancillary Providers
  • Exceptions to Using Horizon Data Submission Template Exceptions to Using Horizon Data Submission Template
  • Supporting Documentation for Ancillary Provider Demographic Updates Supporting Documentation for Ancillary Provider Demographic Updates
  • How to Make Demographic Updates: Participating Practices
  • Provider Data Maintenance Tool Provider Data Maintenance Tool
  • Horizon Data Submission Template Horizon Data Submission Template
  • Specific Criteria You Should Confirm is Accurate and Up to Date Specific Criteria You Should Confirm is Accurate and Up to Date
  • Supporting Documentation Requirements for Practice-level Demographic Updates Supporting Documentation Requirements for Practice-level Demographic Updates
  • Supporting Documentation Requirements for Practitioner Demographic Updates Supporting Documentation Requirements for Practitioner Demographic Updates
  • Creating and Updating Nonparticipating Provider Files Creating and Updating Nonparticipating Provider Files
  • Using CAQH ProView™ Using CAQH ProView™
  • Inquiries, Complaints & Appeals
  • Inquiries Inquiries
  • Complaints Complaints
  • Time Limits for Filing Inquiries/Complaints Time Limits for Filing Inquiries/Complaints
  • Resolving Inquiries/Complaints Resolving Inquiries/Complaints
  • Appeals of Non-Utilization Management Determinations Appeals of Non-Utilization Management Determinations
  • Appeals of Utilization Management/Medical Management Determinations Appeals of Utilization Management/Medical Management Determinations
  • Appeals of Post Service Medical Necessity Determinations Appeals of Post Service Medical Necessity Determinations
  • Medical Policies
  • Allied Health Allied Health
  • Drugs Drugs
  • Introduction Introduction
  • Medicine Medicine
  • Obstetrics Obstetrics
  • Pathology Pathology
  • Radiology Radiology
  • Surgery Surgery
  • Treatment Treatment
  • Hosted Medical Policy Content Hosted Medical Policy Content
  • MCG Care Guidelines MCG Care Guidelines
  • Documentation Submission Guidelines Documentation Submission Guidelines
  • Administrative Policies
  • Allowable Practice Locations for Pathologists Allowable Practice Locations for Pathologists
  • Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers Appointment Availability Access Standards for Primary Care-Type Providers, ObGyns, Specialists and Behavioral Health Providers
  • Credentialing and Recredentialing Policy for Ancillary and Managed Long Term Support Service (MLTSS) Providers
  • Initial Credentialing Initial Credentialing
  • Recredentialing Recredentialing
  • Standards for Participation Standards for Participation
  • Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals Credentialing and Recredentialing Policy for Participating Physicians and Healthcare Professionals
  • Diagnostic Imaging Privileging by Participating Provider Practice Specialty Diagnostic Imaging Privileging by Participating Provider Practice Specialty
  • Digital Member ID Card Policy Digital Member ID Card Policy
  • EDI and NaviNet Claims Submission Requirement EDI and NaviNet Claims Submission Requirement
  • Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT)
  • Material Adverse Change (MAC) Notification Policy Material Adverse Change (MAC) Notification Policy
  • Medical Records Documentation Standards Medical Records Documentation Standards
  • Medicare Advantage Readmission Medicare Advantage Readmission
  • Medicare Part B Utilization Management in the Absence of NCD or LCD Medicare Part B Utilization Management in the Absence of NCD or LCD
  • Never Events Never Events
  • Out-of-Network Referral Policy Out-of-Network Referral Policy
  • Outlier Audit Programs: Post Payment and Pre-Payment Outlier Audit Programs: Post Payment and Pre-Payment
  • Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network Participation Status in Products that Utilize Tiering and/or Subset of an Existing Horizon Network
  • Pass Through Billing (Modifier 90) Pass Through Billing (Modifier 90)
  • Practice Location Reinstatements Practice Location Reinstatements
  • Practice Locations Limit Practice Locations Limit
  • Practitioner Counseling and Termination Policy - Professional Competency Practitioner Counseling and Termination Policy - Professional Competency
  • Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards Practitioner Office Site Quality and Medical/Behavioral Health Record Keeping Standards
  • Provider Directory Management Provider Directory Management
  • Provider Outlier Program Frequently Asked Questions Provider Outlier Program Frequently Asked Questions
  • Retainer Based Medicine Retainer Based Medicine
  • SHBP/SEHBP Inpatient Readmission Reimbursement SHBP/SEHBP Inpatient Readmission Reimbursement
  • Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities Standards for All Types of Medical and Dental Diagnostic Radiology and Imaging Facilities
  • Tier Awareness Policy Tier Awareness Policy
  • Use of Horizon Hospital Network Performance Data Use of Horizon Hospital Network Performance Data
  • Use of Practitioner Performance Data Use of Practitioner Performance Data
  • BlueCard Medical Policies BlueCard Medical Policies
  • Reimbursement Policies & Guidelines
  • Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005) Add-on Payment for COVID-19 Diagnostic Testing Run on High Throughput Technology (U0005)
  • After-hours and Weekend Care After-hours and Weekend Care
  • Allergy Services Allergy Services
  • Ambulance Services Ambulance Services
  • Ambulatory Electrocardiographic Monitoring Ambulatory Electrocardiographic Monitoring
  • Anesthesia Reimbursement Guidelines Anesthesia Reimbursement Guidelines
  • ASC Multiple Procedure Methodology ASC Multiple Procedure Methodology
  • Assistant at Surgery Assistant at Surgery
  • Balloon Sinuplasty Balloon Sinuplasty
  • Bariatric Surgery Billed With Hiatal Hernia Repair Bariatric Surgery Billed With Hiatal Hernia Repair
  • Behavioral Health Services Rendered by Supervised Practitioners Behavioral Health Services Rendered by Supervised Practitioners
  • Bilateral Procedures Bilateral Procedures
  • Billing Guidelines for Maternity Services Billing Guidelines for Maternity Services
  • Biologics Coding Biologics Coding
  • Cardiac Event Detection Cardiac Event Detection
  • Cardiovascular Implant Device Monitoring Services Cardiovascular Implant Device Monitoring Services
  • Casting, Strapping and Splints Casting, Strapping and Splints
  • Chemotherapy Administration Chemotherapy Administration
  • Chronic Care Management Services Chronic Care Management Services
  • Claims Requiring Additional Documentation Claims Requiring Additional Documentation
  • ClaimsXten Editing Rules ClaimsXten Editing Rules
  • Clinical Trials Support Program Clinical Trials Support Program
  • Co-Surgeon Reimbursement Co-Surgeon Reimbursement
  • Collaborative Care Management Services Collaborative Care Management Services
  • Colonoscopy with Modifier 59 Colonoscopy with Modifier 59
  • Conscious Sedation Conscious Sedation
  • Consultation Services Payment Consultation Services Payment
  • Consumable Medical Supplies Consumable Medical Supplies
  • Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies
  • COVID 19 Antibody Testing COVID 19 Antibody Testing
  • COVID-19 Testing and Testing Related Services COVID-19 Testing and Testing Related Services
  • Daily Management of Epidural or Subarachnoid Continuous Drug Administration Daily Management of Epidural or Subarachnoid Continuous Drug Administration
  • Daily Maximum Units for Surgical Pathology and Microscopic Examination Daily Maximum Units for Surgical Pathology and Microscopic Examination
  • Determination of Refractive State Determination of Refractive State
  • Diabetic Screening Services Diabetic Screening Services
  • Diabetic Supplies Diabetic Supplies
  • Distinct Procedural Service Modifiers (59, XE, XP, XS, XU) Distinct Procedural Service Modifiers (59, XE, XP, XS, XU)
  • DME Rent to Purchase DME Rent to Purchase
  • Doula Services Doula Services
  • Drug and Immunization Pricing Drug and Immunization Pricing
  • Duplex Scanning Duplex Scanning
  • Drug Wastage – Modifier JW Drug Wastage – Modifier JW
  • Duplicate Claim Logic for Independent Laboratory Services Duplicate Claim Logic for Independent Laboratory Services
  • Evaluation and Management Services with Chiropractic Manipulative Treatment Evaluation and Management Services with Chiropractic Manipulative Treatment
  • Evaluation and Management Services with Osteopathic Manipulative Treatment Evaluation and Management Services with Osteopathic Manipulative Treatment
  • Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging Evaluation and Management Services billed with Global Radiology, Stress Test, Stress Echo, Myocardial Profusion Imaging
  • False Claims False Claims
  • Free Flap Breast Reconstruction Free Flap Breast Reconstruction
  • Frequency of Care Coordination Services and ESRD Procedures Frequency of Care Coordination Services and ESRD Procedures
  • Frequency of G0179 Frequency of G0179
  • Hip Arthroscopy Hip Arthroscopy
  • Horizon Fee Schedule Updates based on Third Party Sources Horizon Fee Schedule Updates based on Third Party Sources
  • Hospital Non-Patient Laboratory Services
  • Hospital Non-Patient Laboratory Services Sample Fees Hospital Non-Patient Laboratory Services Sample Fees
  • Hot or Cold Pack Therapy Hot or Cold Pack Therapy
  • Inpatient Consultations Inpatient Consultations
  • Knee Arthroscopy Knee Arthroscopy
  • Lab Panel Rebundling Lab Panel Rebundling
  • Laboratory Services Billed by Physicians Laboratory Services Billed by Physicians
  • Laser Treatment of Psoriasis or Parapsoriasis Laser Treatment of Psoriasis or Parapsoriasis
  • Maternity Reimbursement Maternity Reimbursement
  • Maximum Units for Anesthesia Maximum Units for Anesthesia
  • Medical Nutrition Therapy (MNT) Medical Nutrition Therapy (MNT)
  • Medicare Advantage Hospital Sequestration Reimbursement Medicare Advantage Hospital Sequestration Reimbursement
  • Microsurgery and Robotic Surgery Microsurgery and Robotic Surgery
  • Modifier 25 Modifier 25
  • Modifier 50 Bilateral Guidelines Modifier 50 Bilateral Guidelines
  • Modifier 52 Modifier 52
  • Modifier 53 Modifier 53
  • Modifier 54 Modifier 54
  • Modifier 55 Modifier 55
  • Modifier 56 Modifier 56
  • Modifier 57 Modifier 57
  • Modifier 76 Modifier 76
  • Modifier 77 Modifier 77
  • Modifier 78 Modifier 78
  • Modifier SU Modifier SU
  • Modifiers CQ/CO Modifiers CQ/CO
  • Multiple Procedure Reductions Multiple Procedure Reductions
  • Mutually and Non-Mutually Exclusive NCCI Supplemental Edits Mutually and Non-Mutually Exclusive NCCI Supplemental Edits
  • Non-ESRD ESA Level Reporting Non-ESRD ESA Level Reporting
  • Noncovered Related Services Noncovered Related Services
  • Outpatient Consultations Outpatient Consultations
  • Outpatient Facility Claim Coding Requirements Outpatient Facility Claim Coding Requirements
  • Outpatient Facility Code Edits: Bundling and Revenue Codes
  • Bundled Services Bundled Services
  • Lab codes when billed with other services Lab codes when billed with other services
  • Revenue Codes Requiring HCPCS Codes Revenue Codes Requiring HCPCS Codes
  • Typically packaged codes Typically packaged codes
  • Outpatient Laboratory Claims: Referring Practitioner Required Outpatient Laboratory Claims: Referring Practitioner Required
  • Outpatient Services Prior to Admission or Same-Day Surgery Outpatient Services Prior to Admission or Same-Day Surgery
  • Outpatient Therapy Daily Maximum Outpatient Therapy Daily Maximum
  • Physician Extenders Non-Surgical Services Physician Extenders Non-Surgical Services
  • Pre-Payment Coding Reviews Documentation Requests Pre-Payment Coding Reviews Documentation Requests
  • Pre-Payment Documentation Requests: Facility Claims Pre-Payment Documentation Requests: Facility Claims
  • Post Payment Documentation Requests: Facility Claims Post Payment Documentation Requests: Facility Claims
  • Pulmonary Diagnostic Procedures when billed with E&M Codes Pulmonary Diagnostic Procedures when billed with E&M Codes
  • Radiology, Preliminary and Double Reads Radiology, Preliminary and Double Reads
  • Radiopharmaceuticals Radiopharmaceuticals
  • Reimbursement and Billing Guidelines for Anesthesia Claims Reimbursement and Billing Guidelines for Anesthesia Claims
  • Removal of Impacted Cerumen Requiring Instrumentation Removal of Impacted Cerumen Requiring Instrumentation
  • Screening and Diagnostic Mammography & 3D Tomosynthesis Screening and Diagnostic Mammography & 3D Tomosynthesis
  • Site of Service Differential Site of Service Differential
  • Smoking Cessation Smoking Cessation
  • Status N Codes Status N Codes
  • Telemedicine Services
  • Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon BCBSNJ Commercial/ASO plans and products
  • Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage Telemedicine Services Reimbursement Policy: Temporary Addendum for Horizon Medicare Advantage
  • Ulcer Debridement and Ulcer Stages Ulcer Debridement and Ulcer Stages
  • Urgent Care Center Billing Requirements Urgent Care Center Billing Requirements
  • Urinalysis with Evaluation and Management (E&M) Services Urinalysis with Evaluation and Management (E&M) Services
  • Urine Drug Screening/Testing Urine Drug Screening/Testing
  • Vascular Coding Vascular Coding
  • Vitamin D Testing Vitamin D Testing

Utilization Management

  • Utilization Management Request Tool Utilization Management Request Tool
  • Prior Authorization Procedure Search Tool Prior Authorization Procedure Search Tool
  • BlueCard Members BlueCard Members
  • FEP Members FEP Members
  • UNITE HERE HEALTH UNITE HERE HEALTH
  • Patient Quality & Outcome Resources
  • Clinical Practice Guidelines Clinical Practice Guidelines
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Focusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help You Focusing on Your Horizon and Braven Health Patients’ Experience: Tools to Help You
  • Discussion Checklist for CAHPS and HOS Surveys Discussion Checklist for CAHPS and HOS Surveys
  • Cultural Competency Cultural Competency
  • HEDIS Measure Guidelines for Behavioral Health Providers
  • Follow-Up Care for Children Prescribed ADHD Medication (ADD-E) Follow-Up Care for Children Prescribed ADHD Medication (ADD-E)
  • Antidepressant Medication Management (AMM) Antidepressant Medication Management (AMM)
  • Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E) Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)
  • Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP) Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
  • Follow-Up After Emergency Department Visit for Substance Use (FUA) Follow-Up After Emergency Department Visit for Substance Use (FUA)
  • Follow-Up After Hospitalization for Mental Illness (FUH) Follow-Up After Hospitalization for Mental Illness (FUH)
  • Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
  • Follow-Up After Emergency Department Visit for Mental Illness (FUM) Follow-Up After Emergency Department Visit for Mental Illness (FUM)
  • Initiation and Engagement of Substance Use Disorder Treatment (IET) Initiation and Engagement of Substance Use Disorder Treatment (IET)
  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA)
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
  • Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC)
  • Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD) Diabetes Monitoring for People with Diabetes and Schizophrenia (SMD)
  • HEDIS Measurement Year (MY) 2024 Provider Tips for Optimizing HEDIS Results
  • Best Practices Overall for Coding Best Practices Overall for Coding
  • Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)* Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)*
  • Adult Immunization Status (AIS-E) Adult Immunization Status (AIS-E)
  • Adults’ Access to Preventive/Ambulatory Health Services (AAP) Adults’ Access to Preventive/Ambulatory Health Services (AAP)
  • Advanced Care Planning (ACP) Advanced Care Planning (ACP)
  • Antibiotic Utilization for Respiratory Conditions (AXR) Antibiotic Utilization for Respiratory Conditions (AXR)
  • Appropriate Testing for Pharyngitis (CWP) Appropriate Testing for Pharyngitis (CWP)
  • Appropriate Treatment for Upper Respiratory Infection (URI) Appropriate Treatment for Upper Respiratory Infection (URI)
  • Asthma Medication Ratio (AMR) Asthma Medication Ratio (AMR)
  • Avoidance of Antibiotic Treatment for Acute Bronchitis/ Bronchiolitis (AAB) Avoidance of Antibiotic Treatment for Acute Bronchitis/ Bronchiolitis (AAB)
  • Blood Pressure Control for Patients With Diabetes (BPD) Blood Pressure Control for Patients With Diabetes (BPD)
  • Breast Cancer Screening (BCS-E) Breast Cancer Screening (BCS-E)
  • Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
  • Care for Older Adults (COA) Care for Older Adults (COA)
  • Cervical Cancer Screening (CCS) (CCS-E) Cervical Cancer Screening (CCS) (CCS-E)
  • Child and Adolescent Well-Care Visits (WCV) Child and Adolescent Well-Care Visits (WCV)
  • Childhood Immunization Status (CIS) (CIS-E) Childhood Immunization Status (CIS) (CIS-E)
  • Chlamydia Screening in Women (CHL) Chlamydia Screening in Women (CHL)
  • Colorectal Cancer Screening (COL-E) Colorectal Cancer Screening (COL-E)
  • Controlling High Blood Pressure (CBP) Controlling High Blood Pressure (CBP)
  • Deprescribing of Benzodiazepines in Older Adults (DBO) Deprescribing of Benzodiazepines in Older Adults (DBO)
  • Depression Remission or Response for Adolescents and Adults (DRR-E) Depression Remission or Response for Adolescents and Adults (DRR-E)
  • Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
  • Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)
  • Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
  • Eye Exam for Patients With Diabetes (EED) Eye Exam for Patients With Diabetes (EED)
  • Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC) Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC)
  • Follow-Up After Emergency Department Visit for Substance Use (FUA)* Follow-Up After Emergency Department Visit for Substance Use (FUA)*
  • Glycemic Status Assessment for Patients With Diabetes (GSD) Glycemic Status Assessment for Patients With Diabetes (GSD)
  • Immunizations for Adolescents (IMA) (IMA-E) Immunizations for Adolescents (IMA) (IMA-E)
  • Kidney Health Evaluation for Patients with Diabetes (KED) Kidney Health Evaluation for Patients with Diabetes (KED)
  • Lead Screening in Children (LSC) - EPSDT Lead Screening in Children (LSC) - EPSDT
  • Lead Screening in Children (LSC) - NCQA Lead Screening in Children (LSC) - NCQA
  • Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)* Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-E)*
  • Osteoporosis Management in Women Who Had a Fracture (OMW) Osteoporosis Management in Women Who Had a Fracture (OMW)
  • Osteoporosis Screening in Older Women (OSW) Osteoporosis Screening in Older Women (OSW)
  • Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
  • Pharmacotherapy Management of COPD Exacerbation (PCE) Pharmacotherapy Management of COPD Exacerbation (PCE)
  • Postpartum Depression Screening and Follow-Up (PDS-E) Postpartum Depression Screening and Follow-Up (PDS-E)
  • Prenatal Depression Screening and Follow-Up (PND-E) Prenatal Depression Screening and Follow-Up (PND-E)
  • Prenatal Immunization Status (PRS-E) Prenatal Immunization Status (PRS-E)
  • Prenatal and Postpartum Care (PPC) Prenatal and Postpartum Care (PPC)
  • Risk of Continued Opioid Use (COU) Risk of Continued Opioid Use (COU)
  • Statin Therapy for Patients with Cardiovascular Disease (SPC) Statin Therapy for Patients with Cardiovascular Disease (SPC)
  • Statin Therapy for Patients with Diabetes (SPD) Statin Therapy for Patients with Diabetes (SPD)
  • Topical Fluoride for Children (TFC) Topical Fluoride for Children (TFC)
  • Transitions of Care (TRC) Transitions of Care (TRC)
  • Unhealthy Alcohol Use Screening and Follow-Up (ASF-E) Unhealthy Alcohol Use Screening and Follow-Up (ASF-E)
  • Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)* Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)*
  • Use of Imaging Studies for Low Back Pain (LBP) Use of Imaging Studies for Low Back Pain (LBP)
  • Use of Opioids at High Dosage (HDO) Use of Opioids at High Dosage (HDO)
  • Use of Opioids from Multiple Providers (UOP) Use of Opioids from Multiple Providers (UOP)
  • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
  • Well-Child Visits in the First 30 Months of Life (W30) Well-Child Visits in the First 30 Months of Life (W30)
  • HorizonDocs
  • HorizonDocs 2023 Training HorizonDocs 2023 Training
  • Quality Resource Center
  • Educational Materials
  • Achieving Success in Quality Improvement Achieving Success in Quality Improvement
  • Quality Management 2023 Webinars
  • R&R Overview R&R Overview
  • Adult Measures Adult Measures
  • Pediatric Measures Pediatric Measures
  • Optimizing Monthly R&R Reports Optimizing Monthly R&R Reports
  • Overview of Horizon Docs Overview of Horizon Docs
  • Quality Care Gap Closure Quality Care Gap Closure
  • Lead Overview Lead Overview
  • Asthma Medication Ratio Asthma Medication Ratio
  • CWP Overview CWP Overview
  • Risk Adjustment Overview Risk Adjustment Overview
  • CAHPS Overview CAHPS Overview
  • Telehealth Telehealth
  • Women’s Health Women’s Health
  • What’s the Code? What’s the Code?
  • Colorectal Cancer Screening Colorectal Cancer Screening
  • Electronic Claim Data System (ECDS) Supplemental Data File Feed 2024 Electronic Claim Data System (ECDS) Supplemental Data File Feed 2024
  • Results & Recognition Program
  • HEDIS and Quality Management Program Manual HEDIS and Quality Management Program Manual
  • Women’s Health Results and Recognition Program Women’s Health Results and Recognition Program
  • Provider Guidelines: Non-Standard (Medical Record) Supplemental Data for HEDIS Gap Closure
  • Adult HEDIS Measures Adult HEDIS Measures
  • Pediatric HEDIS Measures Pediatric HEDIS Measures
  • How to Submit Supplemental Data to Horizon How to Submit Supplemental Data to Horizon
  • Health Outcomes Survey: How You Can Drive Results Health Outcomes Survey: How You Can Drive Results

Provider Self-Service Tools

  • Drug Authorizations Tool Drug Authorizations Tool
  • Electronic Data Interchange (EDI)
  • Braven Health℠ Electronic Data Interchange (EDI) Braven Health℠ Electronic Data Interchange (EDI)
  • Horizon BCBSNJ Electronic Data Interchange (EDI) Horizon BCBSNJ Electronic Data Interchange (EDI)
  • Eligibility and Benefits Cost Share Estimator Eligibility and Benefits Cost Share Estimator
  • Interactive Voice Response System (IVR)
  • Referral Process Using the Interactive Voice Response System Referral Process Using the Interactive Voice Response System
  • Effective use of the Interactive Voice Response System Effective use of the Interactive Voice Response System
  • NaviNet NaviNet
  • Working with Us: Information & Education Resources
  • Educational Webinars
  • Behavioral Health Training Webinars Behavioral Health Training Webinars
  • Manuals & User Guides
  • Agreements Agreements
  • Ancillary Manual
  • The BlueCard Program The BlueCard Program
  • Claims Submissions and Reimbursement Claims Submissions and Reimbursement
  • Coordination of Benefits Coordination of Benefits
  • HIPAA HIPAA
  • Horizon Behavioral Health Horizon Behavioral Health
  • Horizon Hospital Network Horizon Hospital Network
  • Identification Identification
  • Inquiries, Complaints and Appeals Inquiries, Complaints and Appeals
  • Member Rights and Responsibilities Member Rights and Responsibilities
  • Patient-Centered Programs Patient-Centered Programs
  • Patient Health Support Patient Health Support
  • Policies, Procedures and General Guidelines Policies, Procedures and General Guidelines
  • Products Products
  • Provider Responsibilities Provider Responsibilities
  • Quality Management Quality Management
  • Quality Recognition Programs Quality Recognition Programs
  • Referrals Referrals
  • Service Service
  • Utilization Management Utilization Management
  • Hospital Manual
  • Claims Submission and Reimbursement Claims Submission and Reimbursement
  • Programs Administered by eviCore healthcare Programs Administered by eviCore healthcare
  • Important Resources for Providers Important Resources for Providers
  • Participating Physician and Other Health Care Professional Office Manual
  • At Your Service At Your Service
  • Payment Summaries and Vouchers Payment Summaries and Vouchers
  • Special Programs Special Programs
  • Welcome Kit Welcome Kit
  • Network Specialists
  • Medical Network Specialist Assignments Medical Network Specialist Assignments
  • Behavioral Health Network Specialist Assignments Behavioral Health Network Specialist Assignments
  • Recognition Programs and Partnerships
  • Blue Distinction Centers Blue Distinction Centers
  • New Jersey Infection Prevention Partnership New Jersey Infection Prevention Partnership
  • CMS Training Requirements
  • Compliance Training for Providers Compliance Training for Providers
  • Health Care Fraud, Waste and Abuse Health Care Fraud, Waste and Abuse
  • Prepayment Coding Audit Review Prepayment Coding Audit Review
  • Horizon BlueCard Horizon BlueCard
  • Horizon EPO Horizon EPO
  • Horizon Indemnity/PPO Horizon Indemnity/PPO
  • Navinet Navinet
  • Online Tools
  • Electronic Funds Transfer Electronic Funds Transfer
  • Health Risk Assessment Health Risk Assessment
  • Radiation Therapy Medical Necessity Determination Radiation Therapy Medical Necessity Determination
  • Virtual ID Cards Virtual ID Cards

Forms by Plan Type

  • Dental Dental
  • Medical Medical
  • Pharmacy Pharmacy

Forms by Specialty Type

Forms by type.

  • Appeal / Dispute Appeal / Dispute
  • Assess / Evaluate / Examine Assess / Evaluate / Examine
  • Authorizations Authorizations
  • Braven Health Forms Braven Health Forms
  • Claim Claim
  • Consent Consent
  • Credentialing Credentialing
  • Enroll / Elect / Apply Enroll / Elect / Apply
  • Horizon NJ TotalCare (HMO D-SNP) Forms Horizon NJ TotalCare (HMO D-SNP) Forms
  • Inquiry / Request Inquiry / Request
  • Prescription Drug Mail Order Prescription Drug Mail Order
  • Reimbursement / Payment Reimbursement / Payment
  • Frequently Used Forms Frequently Used Forms
  • Miscellaneous Miscellaneous
  • W9 Form-Dental W9 Form-Dental
  • W9 Form-Medical W9 Form-Medical

Blue Review

  • Blue Review December 2023 Blue Review December 2023
  • Blue Review September 2023 Blue Review September 2023
  • Blue Review March 2022 Blue Review March 2022
  • Blue Review December 2021 Blue Review December 2021
  • Blue Review September 2022 Blue Review September 2022
  • Blue Review September 2021 Blue Review September 2021
  • Blue Review June 2021 Blue Review June 2021
  • Blue Review March 2021 Blue Review March 2021
  • Blue Review June 2023 Blue Review June 2023
  • Blue Review December 2022 Blue Review December 2022
  • Blue Review June 2022 Blue Review June 2022
  • Blue Review March 2023 Blue Review March 2023
  • Blue Review 2020 Blue Review 2020
  • Blue Review 2019 Blue Review 2019

Braven Health Provider News

  • 2024 Issue 1 2024 Issue 1

Feature Stories

  • As Mental Health Needs Continue To Rise, So Do Innovative Virtual Services As Mental Health Needs Continue To Rise, So Do Innovative Virtual Services
  • Treat Knee, Back, and Hip Pain with Orthotic Device that Helps Avoid Invasive Procedures Treat Knee, Back, and Hip Pain with Orthotic Device that Helps Avoid Invasive Procedures
  • Bariatric Surgery Value-Based Program Helps Members with Weight Loss Bariatric Surgery Value-Based Program Helps Members with Weight Loss
  • Dental Providers Benefit from Dedicated Horizon Liaisons Dental Providers Benefit from Dedicated Horizon Liaisons
  • Connecting with parents on the importance of early childhood health screenings and vaccinations Connecting with parents on the importance of early childhood health screenings and vaccinations
  • Episodes of Care Program Gives Cancer Patients the Care They Need Episodes of Care Program Gives Cancer Patients the Care They Need
  • Home-Delivered Meals Help Braven Health℠ Patients Home-Delivered Meals Help Braven Health℠ Patients
  • How a value-based primary care provider helps the New Jersey Vaccination Program How a value-based primary care provider helps the New Jersey Vaccination Program
  • Improving Health Equity through Increased Access to Prenatal Care Across New Jersey Improving Health Equity through Increased Access to Prenatal Care Across New Jersey
  • Pharmacy Collaboration leads to better patient outcomes and cost savings Pharmacy Collaboration leads to better patient outcomes and cost savings
  • Providing Innovative Cancer Care - Expanding Episodes of Care Providing Innovative Cancer Care - Expanding Episodes of Care
  • When planning, collaboration and crisis merge - a medical practice's successful response to COVID-19 When planning, collaboration and crisis merge - a medical practice's successful response to COVID-19
  • News & Legal Notices News & Legal Notices
  • Provider Alerts Provider Alerts

Update: Coverage and Reimbursement for COVID-19 Testing to change

Important information for new covid-19 vaccine claims, code terminations as the phe ends, phe update: prescription limitation change for braven health, hmo d-snp and medicare part d members, important update: additional policy changes as phe ends, some benefits changes as the phe ends, referral requirements for all services, referral requirements for services not related to covid-19, reminder: select one method for covid-19 and influenza testing, antibody testing: fda and cdc do not recommend use to determine immunity, covid-19 vaccine administration reimbursement at uccs, coverage for antibody infusion therapy, reminder to use specific codes when evaluating for covid-19, covid-19 update: telemedicine reimbursement policy addenda, our commitment, our healthcare facilities, braven health℠, horizon behavioral health℠, patient care support, claim submission & billing, inquiries, complaints & appeals, patient quality & outcome resources, working with us: information & education resources, frequently used forms, miscellaneous, w9 form-dental, w9 form-medical, news & legal notices, provider alerts, coordination of benefits.

Coordination of Benefits (COB) applies when expenses for covered services are eligible under more than one insurance program. Usually, one health insurance company has primary responsibility and there is at least one other health insurance company with responsibility for any remaining patient liability. On occasion, an automobile insurance or workers' compensation insurance carrier will be involved.

Regardless of which insurance carriers are responsible, the combined payments are never greater than the actual charges of services and generally are not more than the primary carrier's contract rate. This portion of the manual offers some guidelines to help in COB situations.

Remember to ask your patient if they have other health insurance coverage.

Obligations of Physician to Obtain COB Information and to Bill Primary First

Claims should be submitted to the primary carrier first. You must help with processing forms required to pursue COB with other health care plans and coverages (including and without limitation, workers' compensation, duplicate coverage and personal injury liability). You are required to make diligent efforts to identify and collect information concerning other health care plans and coverages at the time of service. Where Horizon BCBSNJ is, or appears to be, secondary to another plan or coverage, you must first seek payment from such other plan or coverage according to the applicable rules for COB.

HCAPPA Revised COB Rules

The New Jersey state law known as the Health Claims Authorization, Processing and Payment Act (HCAPPA) states that no health insurer can deny a claim while seeking COB information unless good cause exists for the health insurer's belief that other coverage is available; for example, if the health insurer's records indicate that other insurance coverage exists. Horizon BCBSNJ will continue to gather information from members regarding other benefits in an effort to maintain accurate records and have the appropriate health insurer be financially responsible.

Patient Who has Two or More Insurance Plans (other than Medicare, Motor Vehicle Accidents or Workers' Compensation)

If you are providing care to the covered spouse of a Horizon BCBSNJ subscriber who also has his/her own health plan, the spouse's health plan is always primary UNLESS all of the following are true:

  • The spouse is retired.
  • The spouse is also eligible for Medicare.
  • Our subscriber is covered as an active employee and Medicare is not primary under the Medicare Secondary Payer rules. In this event, the Horizon BCBSNJ coverage is primary, Medicare is secondary and the spouse's health plan is tertiary.

If you are providing care to a Horizon BCBSNJ subscriber who also has coverage as a subscriber with another health plan and the subscriber is:

  • An active employee of one group and a retired employee of another. The plan from the group where the employee is active is primary.
  • A retired employee of two groups. The plan in effect the longest is primary.
  • An active employee of two groups. The plan in effect the longest is primary.

When providing care to a dependent child, whose parents are not separated or divorced and:

  • The parents both have health insurance, determine from their benefit plans whether the Birthday Rule or the Gender Rule will apply. In most cases, the Birthday Rule will apply.

When providing care to a dependent child, whose parents are separated or divorced:

  • The plan of the parent who has financial responsibility for health care expenses (as determined by the court) is the primary plan, regardless of who has custody of the child.
  • For claims for a dependent child whose parents are separated or divorced, but a court has not stipulated financial responsibility, the unmarried parent who has custody is primary. The other parent is secondary.
  • Any coverage through a stepparent married to the custodial parent would be next, and the noncustodial parent's coverage last.

BIRTHDAY RULE

Under the Birthday Rule, to determine the primary carrier, you need the month and day of the parents' birth dates; the year is never considered. The parent whose birthday falls earlier in the year has the primary plan for the dependent child. If both parents have the exact same birthday (month and day), the plan in effect the longest is primary. The Birthday Rule will only apply if both carriers use the Birthday Rule.

GENDER RULE

Under the Gender Rule, the father's plan is primary for the dependent child. If one parent's contract uses the Birthday Rule and the other contract uses the Gender Rule, then Gender Rule determines the father's plan as primary.

MOTOR VEHICLE ACCIDENTS

If the primary carrier is:

  • The auto insurance, you must submit your claim to them. After you receive the Explanation of Payment (EOP) from the auto insurance carrier, send it to us with a completed claim form, an itemized bill and a copy of the member's Explanation of Benefits (EOB). Electronic claims cannot be accepted because of the additional information required to process the claim.
  • If the primary carrier is Horizon BCBSNJ, we will need a copy of the automobile declaration sheet with the date of accident between the policy effective date and cancellation date. Be sure to attach an itemized bill and completed claim form.

Automobile insurance is not primary for motorcycle accidents for owner/operators of a motorcycle. However, passengers of motorcycle accidents need to submit any accident-related claims to their auto insurance carrier for consideration.

WORKERS' COMPENSATION

Workers' compensation covers any injury which is the result of a work-related accident. Employers purchase insurance which covers work-related illnesses or injuries.

Horizon does not provide reimbursement for services rendered to treat work-related illnesses or injuries or for services or supplies which could have been covered by workers' compensation.

Always bill the workers' compensation carrier directly for work-related illnesses or injuries. If Horizon Casualty Services, Inc. is the workers' compensation carrier, mail medical bills to:

REGULATIONS ON NEW JERSEY INSURED GROUP POLICY

Special rules apply for Coordination of Benefits (COB) where the Horizon policy is an insured group policy issued by Horizon 11:4-28.7, as amended effective January 1, 2003, provides for different COB rules (as to insured group policies issued in New Jersey) depending on what basis the primary and secondary plans pay and whether the physician is or is not in the network of either or both plans.

If Horizon BCBSNJ is the primary payer, these rules do not apply.

If the Horizon BCBSNJ insured group policy is secondary, and the physician or other health care professional is in Horizon BCBSNJ's network, these rules apply:

  • Where both the primary and secondary plans pay on the basis of a contractual fee schedule and the physician is in the network of both plans, Horizon BCBSNJ pays the cost sharing of the covered person under the primary plan up to the amount Horizon BCBSNJ would have paid if primary, provided that the total amount paid to the physicians from the primary plan, HorizonJ, and the covered person does not exceed the contractual fee of the primary plan and provided that the covered person is not responsible for more than the cost sharing under our plan. (N.J.A.C. 11:4- 28.7(e)1.)
  • Where the primary plan pays on the basis of Usual, Customary and Reasonable (UCR) and Horizon pays on the basis of a contractual fee schedule, the primary plan pays its benefits without regard to the other coverage and Horizon pays the difference between billed charges and the benefits paid by the primary plan up to the amount we would have paid if primary. Our payment is first applied to the covered person's cost sharing under the primary plan. The covered person is only liable for cost sharing under our plan if he/she has no liability for cost sharing under the primary plan and the total payments of the primary and our plan are less than billed charges. The covered person is not responsible for billed charges in excess of the amounts paid by the primary and secondary plans and cost sharing under either plan. The covered person can never be responsible for more than the cost sharing under the secondary plan. (N.J.A.C. 11:4-28.7(e)2.)
  • Where the primary plan pays on the basis of a contractual fee schedule but the secondary pays on the basis of UCR, and the physician or other health care professional is in the network of the primary plan, the secondary plan pays any cost sharing of the covered person under the primary plan up to the amount the secondary would have paid if primary. (N.J.A.C. 11:4-28.7(e)3.)
  • Where the primary plan is an HMO plan but the physician or other health care professional is out of network and services are not covered by the primary plan, Horizon BCBSNJ pays as if it were primary. (N.J.A.C. 11:4-28.7(e)4.)
  • Where the primary plan pays capitation and Horizon BCBSNJ's plan is an HMO plan that pays on a contractual fee schedule and the physician or other health care professional is in the network of both plans, Horizon pays the cost sharing of the covered person under the primary plan up to the amount Horizon would have paid if primary. (N.J.A.C. 11:4-28.7(e)5.)
  • Where the primary plan pays capitation, contractual fee schedule or UCR, and Horizon BCBSNJ's plan pays on a capitated basis, Horizon pays its capitation and the covered person has no responsibility for payment of any amount for eligible services. (N.J.A.C. 11:4-28.7(e)6.)
  • Where the primary and Horizon's plan are both HMO plans and the physician or other health care professional is not in the primary plan's network, and the primary has no liability, Horizon pays as if primary. (N.J.A.C. 11:4-28.7(e)7.)

MEDICARE ELIGIBILITY

There may be instances when an individual who has coverage with us may also be entitled to Medicare coverage. This section will help you to determine which plan will pay as primary.

COB when Medicare is involved is usually called Medicare Secondary Payer (MSP). MSP does not apply to members who have individual contracts. Medicare is always primary for individual contract holders.

There are three ways a person can become eligible for Medicare:

  • Attaining age 65
  • Becoming disabled
  • Having end-stage renal disease (ESRD)

Attaining Age 65

When individuals reach age 65 and have contributed enough working quarters into the Social Security system, they are entitled to Medicare Part A benefits at no cost. To receive Medicare Part B benefits, they must pay premiums through monthly deductions from their Social Security checks.

For individuals who have not contributed enough quarters in the Social Security system, there are two ways they may receive Medicare Part A benefits:

  • Through a spouse who has contributed enough quarters to the Social Security system. This is identified by the letter B following the spouse's Medicare claim number on his or her Medicare ID card.
  • Purchase Medicare Part A benefits. This is identified by the letter M following the Medicare claim number on his or her Medicare ID card.

Becoming Disabled

Disabled individuals under age 65 are entitled to Medicare under the disability provisions of the Social Security Act. They must be unable to work and must have been receiving Social Security disability payments for 24 months. Beginning with the first day of the 25th month of receiving Social Security payments, they are entitled to Medicare Part A benefits at no cost. Medicare Part B benefits may be purchased.

Having End-Stage Renal Disease (ESRD)

A person becomes eligible for Medicare under the ESRD provisions after beginning a regular course of renal dialysis. He/She is entitled to Medicare benefits after completing a three-month waiting period beginning the first day of the month after the start of a regular course of renal dialysis. The waiting period continues until the first day of the fourth month following the initiation of renal dialysis. On the first day of the fourth month, such a person is entitled to Medicare Part A at no cost.

Medicare Part B benefits may be purchased.

The three-month eligibility waiting period for ESRD Medicare benefits may not apply when the Medicare-eligible individual:

  • Receives a kidney transplant. In this circumstance, the individual is entitled to Medicare the first day of the month in which the transplant occurred.
  • Initiates a course of self-dialysis training during the three-month waiting period. In this circumstance, the individual becomes entitled to Medicare the first day of the month of his or her eligibility.

MEDICARE SECONDARY PAYER

There are three ways a Medicare-eligible person may be primary with us under an employer group health program:

  • Working-aged
  • End-stage renal disease (ESRD)

See chart on the next page for more detailed information.

Working-Aged

When a person becomes entitled to Medicare at age 65, there is the possibility that he or she has health insurance through an employer group health account. It is important to know whether the policyholder (subscriber) is retired or actively working.

To determine who is primary, three questions need to be asked of the Medicare beneficiary who has a group health policy through Horizon BCBSNJ:

  • Are you or your spouse actively employed?
  • Are there 20 or more employees (regardless if full-time or part-time employees) where you or your spouse work?
  • Are you covered under that insurance policy?

If the answers to all three questions are YES, then the Horizon BCBSNJ group health policy would be primary to Medicare for the Medicare-eligible person.

Special Enrollment Period for Medicare Part B Benefits

A Medicare-eligible person may choose not to purchase Medicare Part B since it may not be necessary if the group is primary. When Medicare becomes primary, the subscriber may sign up for Medicare Part B benefits, with no increase in premiums. Coverage begins the first day of the month following the month the primary coverage ends. The person must sign up immediately upon becoming eligible once Medicare is primary, since the Medicare Part B benefits will only begin the first of the month that he/she signs up. This is called the Special Enrollment Period (SEP).

If an individual is entitled to Medicare because of age and is covered under the MSP provisions, he/she has the right to select Medicare as primary. If the person selects Medicare as primary, he/she must be dropped from his/her employer's group health benefits with the exception of prescription drug and dental coverage. The employer may not subsidize a supplemental Medicare plan under these circumstances.

If Medicare is primary and the subscriber chooses not to purchase Medicare Part B benefits, we will never pay more than we would have if that individual had Medicare Part B benefits. In addition, this person would not be eligible for the SEP and would face increased premiums and be restricted when he/she signs up for Medicare Part B benefits.

If you need help understanding if Medicare or a group health plan is primary, call the CMS Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 .

* This does not apply if the member was Medicare-eligible due to age or disability prior to ESRD eligibility and the group health plan was primary due to other Medicare Secondary Payer rules. In this case, the group health plan would remain primary for the first 30 months of ESRD eligibility.

MEDICARE EXCEPTIONS

MSP regulations only apply when the insurance coverage is through an employer. A Medicare supplemental policy, or Medigap policy, may be offered by an employer (if there are less than 20 employees or if the employee is not actively working) or it may be purchased on an individual basis; however, a Medicare supplemental policy will never be primary over Medicare.

Medicare Part A

If there are no Medicare Part A benefits, MSP regulations do not apply. Medicare Part A services are billed to the group health plan.

Individuals who have purchased Medicare Part A benefits are identified with an M at the end of the Medicare claim number on their Medicare ID card.

Individuals entitled to Medicare due to disability must be under the age of 65, otherwise the working-aged provisions apply. You should ask the following questions to determine primacy:

  • Are you, your spouse or a family member actively employed?
  • Are there 100 or more employees (regardless if full-time or part-time) where you, your spouse or family member works?
  • Are you covered by that insurance policy?

The two important differences between the MSP working-aged and the disability provisions are:

  • Who the active employee is; and
  • The number of employees in the group.

Unlike the working-aged provisions, under the MSP disability provision, the Medicare-eligible individual may be covered by a family member other than his/her spouse. This typically occurs when a parent or legal guardian covers a disabled dependent – either child or adult.

Under the disability provisions, the employer must employ 100 or more employees. It is important to verify the number of employees because the patient may be part of a subgroup within a group, such as the New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP). There may be local municipalities with fewer than 100 employees, but the larger group has greater than 100 employees. The number of employees in the entire employer group is considered when making the determination of eligibility for Medicare due to disability.

  • The patient is entitled to Medicare due to disability. He is not actively working, but his wife is and she has family health coverage through her employer, which has more than 100 employees. The patient would be primary under his wife's group health policy since she is actively employed by an employer of 100 or more employees and her group health insurance covers him.
  • A patient is entitled to Medicare due to disability and is covered under his mother's insurance. She is actively employed and has family group health coverage through the employer who employs more than 100 individuals. In this case, the son's primary insurance is the mother's group health insurance plan.
  • The patient is Medicare-eligible due to disability and is actively employed by a municipality that provides group health coverage. While she is no longer collecting Social Security disability payments, she still continues under the Medicare program. The municipality has only 35 employees but their health coverage is through the New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP), and the state employs more than 100 individuals. The group health insurance would be primary for the patient and Medicare would be secondary.
  • A local union may appear to employ fewer than 100 employees, however, the patient's coverage is through the Health and Welfare Fund for all union members. If just one of the local unions that belong to that Health and Welfare Fund has 100 or more employees, then any local union covered by the Health and Welfare Funds health plan would be covered by the MSP regulations.

End-Stage Renal Disease (ESRD)

A person becomes Medicare-eligible due to ESRD when he or she begins a regular course of renal dialysis. There is a three-month waiting period to receive Medicare Part A and Part B benefits (unless an exception applies).

When a person is entitled to Medicare due to ESRD, the MSP regulations will apply when:

  • The patient has group health coverage of their own or through a family member (including spouse).
  • That group health coverage is through a current or former employer.

When the Medicare beneficiary meets the above conditions, he/she is primary under the group health coverage for a specific period of time known as the Coordination of Benefit (COB) period. The COB period always begins on the first date of entitlement, and all medical services are covered by the group health coverage – not just renal services.

If the individual became entitled to Medicare due to ESRD, they have a 30-month COB period, beginning with the first date of entitlement.

  • Medicare was already paying primary for a Medicare-eligible individual due to attaining age 65 or disability because they did not fall under either the Working-Aged or Disability provisions.

Are you sure you want to leave this website?

You are leaving the Horizon Blue Cross Blue Shield of New Jersey website. Please click Continue to leave this website. Or, if you would like to remain in the current site, click Cancel.

Please note that these forms are to be used by Federal Employee Program Members only

IMAGES

  1. Fillable Bcbs Coordination Of Benefits Questionnaire printable pdf download

    what is coordination of benefits bcbs

  2. How To Read Bcbs Explanation Of Benefits

    what is coordination of benefits bcbs

  3. Coordination of Benefits Questionnaire Form

    what is coordination of benefits bcbs

  4. EXPLAINED: What is Coordination of Benefits? (aka COB)

    what is coordination of benefits bcbs

  5. PPT

    what is coordination of benefits bcbs

  6. PPT

    what is coordination of benefits bcbs

VIDEO

  1. Power of Baking Soda for Healthier Skin and Toenails!

  2. What Happens To Your Body When You Eat Pistachios Every Day

  3. After BCA Off Campus Placement

  4. Bcom |Guidance Part 2

  5. BCOM BBA or BCA which one??

  6. BCA Course| Jobs after BCA

COMMENTS

  1. For Members: What is coordination of benefits?

    Insurance companies coordinate benefits to: Avoid duplicate payments by making sure the two plans don't pay more than the total amount of the claim Establish which plan is primary and which plan is secondary—the plan that pays first and the plan that pays any remaining balance after your share of the costs is deducted

  2. What Is Coordination of Benefits?

    Coordination of benefits helps: Avoid duplicate payments by making sure the two plans don't pay more than the total amount of the claim. Ensure the appropriate payments are made by each plan. Reduce the cost of insurance premiums.

  3. What Is Coordination of Benefits?

    Coordination of benefits helps: Avoid duplicate payments by making sure the two plans don't pay more than the total amount of the claim. Ensure the appropriate payments are made by each plan. Reduce the cost of insurance premiums.

  4. PDF What is coordination of benefits? Who pays first How the claim ...

    EMPOWER What is coordination of benefits? Some Blue Care Network members have health care or prescription drug coverage from more than one source. For example, a person may be covered under a spouse's health plan, or a child may be covered under the plans of both parents.

  5. Coordination of Benefits and Patient Share

    Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits. This article is meant to assist physicians and other professional providers, and facilities in understanding the coordination of benefits clause from the contracting perspective.

  6. Coordination of Benefits

    Coordination of benefits (COB) COB is our process for ensuring that our members receive full benefits and helping to prevent over-payment for services when a member has coverage from two or more sources. Blue Cross follows NAIC (National Association of Insurance Commissioner) and CMS (Centers for Medicare and Medicaid Services) guidelines.

  7. Coordination of Benefits and Patient Share

    Coordination of Benefits and Patient Share. Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits. ... The information contained in this article applies to member's health benefit policies issued by Blue Cross and Blue Shield of ...

  8. PDF BCN: What is coordination of benefits?

    Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Asso ciation. Blue Care Network . What is coordination of benefits? Some Blue Care Network members have health care or prescription drug coverage from more than one source. For example, a person may be covered under a spouse ...

  9. PDF Your guide to who pays first.

    Coordination of benefits If you have Medicare and other health coverage, you may have questions about how Medicare works with your other insurance and who pays your bills first . Each type of coverage is called a "payer ." When there's more than one payer, "coordination of benefits" rules decide who pays first .

  10. PDF Coordination of Benefits.

    LET'S GET STARTED It's important to know how Medicare works with other kinds of health or drug coverage, and who should pay your bills first. This is called "coordination of benefits." If you have Medicare and other health or drug coverage, each type of coverage is called a "payer."

  11. Coordination of Benefits

    Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more t...

  12. PDF What Is Coordination of Benefits?

    What Is Coordination of Benefits? If you have more than one medical or dental insurance plan, you are required to provide this information for your plans to work together, so your claims can be processed correctly and you can get the most out of your coverage. You May Need Coordination of Benefits If:

  13. Coordination of Benefits

    Expand All Medical and dental coverage Married couples Healthy newborns and other dependents Reimbursement for coordination of benefits claims We will pay the balance up to the amount we would have paid if we had been the primary insurer.

  14. PDF Coordination of Benefits Questionnaire

    Coordination of Benefits Questionnaire +.V BlueCross BlueShield of North Carolina Your Blue Cross Blue Shield contract may contain a Coordination of Benefits (COB) provision. We depend upon your help in order for us to process your claims correctly and appreciate your prompt and accurate reply.

  15. Coordination of Benefits

    Coordination of Benefits What is coordination of benefits. Coordination of Benefits (COB) applies when an individual has coverage under more than one Health Benefit Plan. Arkansas Blue Cross and Blue Shield may coordinate benefits between the health insurances covering the individual.

  16. What is Coordination of Benefits & How Does it Work?

    When a person is covered by two health plans, coordination of benefits is the process the insurance companies use to decide which plan will pay first for covered medical services or prescription drugs and what the second plan will pay after the first plan has paid. Why is Coordination of Benefits important?

  17. - Blue Cross and Blue Shield's Federal Employee Program

    We can help you select the right Service Benefit Plan option to combine with Medicare. Using Your Benefits Get the most out of your Blue Cross and Blue Shield Federal Employee Program (FEP) coverage with Medicare. Standard Option Benefits Chart Here's a look at the Standard Option benefits in a chart. Basic Option Benefits Chart

  18. Coordination of Benefits

    Coordination of Benefits (COB) applies when expenses for covered services are eligible under more than one insurance program. Usually, one health insurance company has primary responsibility and there is at least one other health insurance company with responsibility for any remaining patient liability. On occasion, an automobile insurance or workers' compensation insurance carrier will be ...

  19. PDF Coordination of Benefits Questionnaire

    If you, your spouse or any of your covered dependents do not have coverage through another healthcare plan, you can update your coordination of benefits information easily by using one of these methods: 1) Call our automated response number at 1-866-263-9494 or 2) Login to our mobile app and click Coordination of Benefits under My Account from ...

  20. PDF Coordination of Benefits Questionnaire

    Member: Your Blue Cross and/or Blue Shield contract may contain a Coordination of Benefits (COB) provision. Your Plan depends upon your help in order to process your claims correctly and appreciates your prompt and accurate reply. If any of the information below changes, please contact your Blue Cross and/or Blue Shield Plan immediately.

  21. Coordination of Benefits

    Coordination of Benefits Upload date. Apr 24, 2023. View PDF. Jan 23, 2020. View PDF. Feb 18, 2019. Editorial Category Change. View PDF. Feb 18, 2019. editorial category change. View PDF. ... Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. ...

  22. What Is Coordination of Benefits?

    This is called Coordination of Benefits. If there are instances where you need more benefits to cover your health expenses than your primary plan covers, the secondary plan may pay part of a claim or an additional amount toward the claim, based on its coordination of benefits rules. ... Blue Cross and Blue Shield of New Mexico, a Division of ...

  23. PDF 2024 SECUREBLUEMSHO SUPPLEMENTAL BENEFITS

    Members may also call 1-855-788-3466 from 8 AM to 7 PM CT. This number is automated to prompt activation and share card balance. For members who need to speak to a customer service representative call 1-855-788-3466 and follow the prompts. If a member loses their card, call 1-855-788-3466 to request a replacement card.

  24. What Is Coordination of Benefits?

    This is called Coordination of Benefits. If there are instances where you need more benefits to cover your health expenses than your primary plan covers, the secondary plan may pay part of a claim or an additional amount toward the claim, based on its coordination of benefits rules. ... Blue Cross and Blue Shield of Texas, a Division of Health ...