Re: Covered Entity or not

[Zon Owen]

Susan,   There are two models of COB.   One of these, which I will call Model A, does not require use of a separate COB standard.  The X12 837 (claim) transaction allows a provider to report an earlier payer's reimbursement when billing the next payer.  That is the Provider-to-Payer-A-to-Provider-to-Payer-B model.   Model B, or Provider-to-Payer-A-to-Payer-B COB, is what the COB provisions of the TCS regulations address.  Here, again, the X12 837 is used, but now Payer A reports how it paid directly to Payer B, instead of forcing the provider to do so.   This is usually done when two payers share a substantial volume of multi-payer claims, such as between a Medicare Payer and a Medicare Supplemental Plan, or between Medicare and Medicaid, or either of those and a local BC/BS Plan.   If a provider is using Model A COB, their COB transaction coveredness is essentially a subset of their claims transaction coveredness.  If they do any claims electronically, whether with single or multiple payers, they are covered.   Under Model B, only the Health Plan's coveredness is an issue.  Whether two health plans conduct COB at all is a business decision.  If they do so, and also choose to do it electronically, they must use the 837.  But that is their choice, and doesn't affect the coveredness of the providers that submitted the associated claims to Payer A.   Are their any other thoughts on this out there?       - Zon Owen - (808)597-8493 ----- Original Message -----   From: [EMAIL PROTECTED] To: WEDI SNIP Privacy Workgroup List Sent: Tuesday, February 04, 2003 6:40 PM Subject: Re: Covered Entity or not Does the HIPAA regulation not mention Coordination of Benefits (COB) as one of the reasons a physician might be a covered entity?  How else will COB come into play? Susan Bowes PPC. LLC --- --- The WEDI SNIP listserv to which you are subscribed is not moderated. The 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/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-privacy as: archive@mail-archive.com To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org