Coordination of Benefits and the Contract Profile

The optional Coordination of Benefits (COB) feature allows you to define the method of calculating expected reimbursement for secondary and tertiary payors at the contract profile level. The COB feature includes a list of standard payor calculation methods included in most contract language. Use the Edit Contract Profile page to apply one of these calculation methods to an individual contract profile.

With COB fully enabled for your facility, you can define COB language for secondary and tertiary payments in the following ways:

  • You can select a standard calculation method for both secondary and tertiary payors and apply it to a specific contract profile. The selected calculation method is used to calculate secondary and tertiary reimbursement for all accounts that list this profile as a secondary or tertiary product. Your facility can choose whether to define secondary payors only or both secondary and tertiary. For more information about defining COB settings at the contract profile level, refer to Edit a Contract Profile.
  • You can assign a language category of either Favorable or Unfavorable to indicate profiles where the likelihood of collecting is either favorable or unfavorable. You can then use the language category to filter accounts in the Payor Worklist to focus on those accounts with a high likelihood of being collected.
  • When researching a specific account, you can use the secondary payor profile terms and coordination of benefits language to calculate the expected reimbursement for that account on an ad-hoc basis. The results of this ad-hoc calculation display on the Reprice Comparison page, but are not stored or written to a report. For more information, refer to Calculate Reimbursement. With COB fully enabled, you can only use this feature while reviewing the reprice details for a primary payor.

Even without the full Coordination of Benefits feature enabled, there are still some basic COB features available to you that allow you to define the coordination of benefits language settings used to calculate secondary payor expected reimbursements.

  • You can select a standard secondary payor calculation method and apply it to a specific contract profile. The selected calculation method is used to calculate secondary reimbursement for all accounts that list this profile as a secondary product. Without COB fully enabled, this is limited to secondary reimbursement and does not include tertiary. The display of this information is limited to the COB reports and does not display within Contract Manager. For more information about defining COB settings at the contract profile level, refer to Edit a Contract Profile.
  • You can select a standard secondary payor calculation method and apply it across multiple profiles simultaneously. The selected calculation method is used to calculate secondary reimbursement for all accounts that list any of the selected profiles as a secondary product. For more information about defining COB settings to multiple contract profiles, refer to Update Coordination of Benefits Settings.
  • This page allows you to update COB settings across multiple contract profiles simultaneously and can be used to define these settings quickly, prior to completely enabling COB for your facility. Once COB is fully enabled, changes to the contract profiles impact reprice calculations and must go through the standard check out and check in process. Once COB is fully enabled this page is no longer available and changes to contract profiles must be made one at a time through the Edit Contract Profile page.
  • When researching a specific account, you can use the secondary payor profile terms and coordination of benefits language to calculate the expected reimbursement for that account on an ad-hoc basis. The results of this ad-hoc calculation display on the Reprice Comparison page, but are not stored or written to a report. For more information, refer to Calculate Reimbursement. With COB fully enabled this feature is still available, but can only be used when you are reviewing reprice details for a primary payor. This feature must be enabled for your facility and for each user that needs to access it.

If COB reports are enabled for your facility, the results of the secondary payor reimbursements that are calculated according to the COB settings in a contract profile are written to one of three reports, depending on the language category selected in the profile. These reports include the following:

  • Secondary Payor Reprice - Favorable Report – Shows secondary reimbursement detail for accounts that product matched and repriced according the COB settings in the contract profile. This report is typically used to identify accounts with a high likelihood of being collected and only includes accounts with the following COB settings in the secondary payor contract profile:
    • Calculation Method – Any value other than None
    • Language Category – Favorable
    • Reprice - Yes
  • Secondary Payor Reprice - Unfavorable Report – Shows secondary reimbursement detail for accounts that product matched and repriced according the COB settings in the contract profile. This report is typically used to identify accounts with a low likelihood of being collected and only includes accounts with the following COB settings in the secondary payor contract profile:
    • Calculation Method – Any value other than None
    • Language Category – Unfavorable
    • Reprice - Yes
  • Secondary Payor Reprice - Exception Report – Shows accounts that failed to reprice, failed to product match, or that matched to a secondary payor contract profile where the COB settings were set to not reprice. This includes accounts with the following COB settings in the secondary payor contract profile:
    • Calculation Method – None. If this field is set to None, the secondary reimbursement detail appears on the exception report, even if the other parameters are set to valid values.
    • Language Category – None. If this field is set to None, the secondary reimbursement detail appears on the exception report, even if the other parameters are set to valid values.
    • Reprice - No or None