There is COB in the Medicaid/Medicare world and they are payers.
http://www.hcfa.gov/medicare/cob/home.htm Regards, David Frenkel Business Development GEFEG USA Global Leader in Ecommerce Tools www.gefeg.com 425-260-5030 -----Original Message----- From: Fody, Kenneth W. [mailto:[EMAIL PROTECTED]] Sent: Thursday, July 11, 2002 4:00 PM To: 'WEDi/SNIP ID & Routing' Subject: RE: CPP and COB William: >From a practical perspective, COB is indeed currently up to the provider -- because that is the way COB exists today. Payers really don't exchange data. However, under HIPAA, COB is a transmission from any covered entity -- payer or provider -- to a payer. So the door is open for a payer to require another payer to accept a direct COB transmission, or for a new business model to develop. Does it behoove a Payer to accept a COB transmission from a provider, HIPAA notwithstanding? Absolutely. You also asked what agreement needs to be in place for COB between two parties. From a transaction perspective, I'd say a trading partner agreement. There may be other language needed from a business perspective, for example if the provider is a participating provider, or perhaps getting the provider to agree not to bill the member while awaiting the COB payment. But I'm not sure the latter point is relevant to this discussion. With regard to your question about which type of COB I was referring to when commenting on routing issues, you are correct that I was speaking of Payer to Payer. I think you are correct saying the Provider to Payer to Provider model is simpler, or at least more consistent with what will routinely take place. But all of that being said, look for Payer to Payer COB to pick up in the future. First, if I were a provider, I'd rather one of the Payers just send payment in full and let them figure who pays what. If the carriers and providers don't reach agreement on that concept, then how long will it be before someone lobbies a legislature or regulators to require carriers to interact that way? I don't mean the last point to be negative, just realistic. Ken Fody -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Thursday, July 11, 2002 6:30 PM To: 'WEDi/SNIP ID & Routing' Subject: Re: CPP and COB Ken: The gist of Kepa's Myth #233: "COB claims" seems to be saying that COB (at least the Provider-to-Payer-to-Provider model) is up to the provider: if the secondary payer doesn't heed the previous amounts paid by the primary insurer, he could end up paying as a primary insurer himself! Now don't push me any further on this: I barely understand what I just wrote!! But what agreement needs to be in place between the provider and payer(s) in this case? Isn't Kepa's point mostly that insurers have a rational business imperative to support COB, regardless of any agreements between payers and providers? I'm not obsessed over COB, mind you, but I just want to figure out what we need in the CPP to assist payers and providers in processing claims with COB. On another matter, when you talk about "a fair amount of routing," are you referring solely to the payer-to-payer type of COB? At least the Provider-to-Payer-to-Provider model seems to be no more complicated (in terms of routing) than what we've been talking about all along: i.e., provider using the payer ID to find the payer's CPP and then extracting the appropriate EDI address to which send the interchange. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Fody, Kenneth W." <[EMAIL PROTECTED]> To: "'WEDi/SNIP ID & Routing'" <[EMAIL PROTECTED]> Sent: Monday, 08 July, 2002 10:21 AM Subject: RE: CPP and COB Larry, William, et al -- I would agree with Larry's point with regard to COB on both aspects. First, for a payer to accept a COB transaction from either a provider or another payer, there will have to be some type of agreement in place between the sender and receiver -- the same way there is with any other transaction. This is particularly true if a Payer is truly hoping to use EDI to simplify and improve their COB process, because real improvement requires a lot more work than just taking in an 837. Second, I agree with Larry that CPP is valuable in this context and I would offer a some details on why that is true. Independence Blue Cross and Aetna are the two biggest players in the tri-state Philadelphia area (e.g. PA/southern NJ/DE). Lets say we decided to collaborate on COB. If you look behind the curtain, you'll see Aetna is not just one company. Rather Aetna is a lot of different HMOs -- probably at least one for every state in which they do business -- and some insurance companies all trading under the name Aetna. And the same is true for us, albeit not on as grand a scale. We do business in just three states, but we have six different entities underwriting coverage and a TPA. All of these use the same entry point for electronic transactions. So, as you can see, when two carriers get together to do COB, Larry is correct when he says it is not just a connect and send type of arrangement. There clearly is a fair amount of routing that has to take place, which depends on one party correctly identifying the other carrier to whom they are sending the transaction. As Larry said, anything that makes that process easier is a good thing. Ken Fody Independence Blue Cross discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. 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