COB Language Types

For secondary and tertiary payors, the expected payment is determined by specific COB language that is included in most contracts. The following table defines each of the language types currently defined in Contract Manager.

Payor Class

Calculation Method

Calculation Description

Calculation Text

Secondary

A

The difference between billed charges and the primary actual payment, not to exceed billed charges

(Billed charges - primary actual payment) <= billed charges

Tertiary

A

The difference between billed charges and the sum of all other actual payments, not to exceed billed charges

(Billed charges - all other actual payments) <= billed charges

Secondary

B

The difference between the secondary total expected payment and the primary actual payment, not to exceed the secondary total expected payment

(Secondary total expected payment - primary actual payment) <= secondary total expected payment

Tertiary

B

The difference between the tertiary total expected payment and the sum of all other actual payments, not to exceed the tertiary total expected payment

(Tertiary total expected payment - all other actual payments) <= tertiary total expected payment

Secondary

C

The difference between the primary contracted allowable and the primary payment, not to exceed the secondary contracted allowable

(Primary contracted allowable - Primary payment) <= Secondary contracted allowable

Tertiary

C

The difference between the sum of all other contracted allowables and the sum of all other payments, not to exceed the tertiary contracted allowable

(Sum of all other contracted allowables) - (Sum of all other payments) <= Tertiary contracted allowable

Secondary

 

D

 

Other - Requires Manual Calculation

Requires Manual Calculation

Note: Type D requires a manual calculation. No calculation is actually performed, the secondary expected payment is set to zero. This type enables users to more easily identify problematic language files.

Secondary

E

The difference between billed charges and the primary payment

(Billed charges - Primary payment)

Tertiary

E

The difference between billed charges and the sum of all other payments

(Billed charges - (Sum of all other payments))

Secondary

F

The difference between billed charges and the primary total expected payment

(Billed charges - Primary total expected payment)

Tertiary

F

The difference between billed charges and the sum of all other total expected payments

(Billed charges - (Sum of all other total expected payments))

Secondary

G

The difference between the secondary total expected payment and the primary payment

(Secondary total expected payment - Primary payment)

Tertiary

G

The difference between the tertiary total expected payment and the sum of all other payments

(Tertiary total expected payment - (Sum of all other payments))

Secondary

H

The difference between the secondary total expected payment and the primary total expected payment

(Secondary total expected payment - Primary total expected payment)

Tertiary

H

The difference between the tertiary total expected payment and the sum of all other expected payments

(Tertiary total expected payment - (Sum of all other expected payments))

Secondary

 

J

 

Patient Liability Portion

Primary payor’s patient liability

Note: For Type J, Patient Liability Portion calculation reliability can be compromised when multiple RAs are received. The patient liability amount may be overwritten by subsequent RA patient liability amounts, thus impacting the secondary/tertiary expected payments.

Secondary

M

Override – Patient liability used when primary payor is Medicare \ Medicaid \ Medi-Cal

Primary payor’s patient liability

Tertiary

 

M

 

Override – Zero when primary payor is Medicare \ Medicaid \ Medi-Cal

Zero

Note: For Type M, Override is a facility controlled COB language type logic:

It uses the language type specified in the contract profile except when the primary payor is Medicare, Medicaid, or Medical. In this case the secondary expected payment is set to the patient liability amount of the primary payor.

In the case of a tertiary payer, the expected amount is equal to the patient liability of the secondary payor.

The reliability of this type can also be compromised when multiple RA’s are received. The patient liability amount can be overwritten by subsequent RA patient liability amounts, thus impacting the secondary/tertiary expected payments.

A facility flag controls this behavior and it is enabled by default, however it can be disabled at the clients’ request. This calculation method may not be selected in the interface.