November 28, 2000
Medi-869-00
TO: ALL MEDICARE PROVIDERS
SUBJECT: COORDINATION OF BENEFITS CONTRACTOR
PRIMARY INTERESTS: BUSINESS OFFICE MANAGERS
The Health Care Financing Administration has requested all Medicare contractors to publish the attached information.
Effective January 1, 2001, please refer all MSP inquiries; including, the reporting of potential MSP situations, changes in a beneficiary’s insurance coverage, changes in employment, and general MSP questions/concerns to the COB Contractor. Continue to call RGBA regarding claims-related questions. The COB Contractor’s Customer Call Center toll free number is 1-800-999-1118 or TDD/TYY 1-800-318-8782. Customer Service Representatives are available to assist you from 8 AM to 8 PM, Monday through Friday, Eastern Standard Time, except holidays.
THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER STAFF. NO COST COPIES ARE ALSO AVAILABLE FROM OUR WEB SITE AT riverbendgba.com
Please refer any questions to our office toll-free at 877- 296- 6189.
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COB Contractor Fact Sheet for Providers |
The Health Care Financing Administration (HCFA) has embarked on an important initiative to further expand its campaign against Medicare waste, fraud and abuse under the Medicare Integrity Program. HCFA awarded the Coordination of Benefits (COB) contract to consolidate the activities that support the collection, management, and reporting of other insurance coverage of Medicare beneficiaries.
The awarding of the COB Contract provides many benefits for employers, providers, suppliers, third party payers, attorneys, beneficiaries, and Federal and State insurance programs. All Medicare Secondary Payer (MSP) claims investigations will be initiated from, and researched at the COB Contractor. This will no longer be a function of your local Medicare fiscal intermediary (FI) or carrier. Implementing this single-source development approach will greatly reduce the amount of duplicate MSP investigations. This will also offer a centralized, one-stop customer service approach, for all MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries that serve to protect the Medicare Trust Funds. The COB Contractor will provide customer service to all callers from any source, including but not limited to beneficiaries, attorneys/other beneficiary representatives, employers, insurers, providers, and suppliers.
Information Gathering
Medicare generally uses the term Medicare Secondary Payer or "MSP" when the Medicare program is not responsible for paying a claim first. The COB contractor will use a variety of methods and programs to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare. In such situations, the other health plan has the legal obligation to meet the beneficiary’s health care expenses first before Medicare. The table below describes a few of these methods and programs.
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Method/Program |
Description |
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Initial Enrollment Questionnaire (IEQ) |
Beneficiaries are sent a questionnaire about other insurance coverage approximately three (3) months before they are entitled to Medicare. |
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IRS/SSA/HCFA Data Match |
Under the Omnibus Budget Reconciliation Act of 1989, employers are required to complete a questionnaire that requests Group Health Plan (GHP) information on identified workers who are either entitled to Medicare or married to a Medicare beneficiary. |
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MSP Claims Investigation |
This activity involves the collection of data on other health insurance that may be primary to Medicare based on information submitted on a medical claim or from other sources. |
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Voluntary MSP Data Match Agreements |
Voluntary Agreements allow for the electronic data exchange of GHP eligibility and Medicare information between HCFA and employers or various insurers. |
Provider Requests for Claims Payment
FIs and carriers will continue to process claims submitted for primary or secondary payment. Claims processing will not be a function of the COB Contractor. Questions concerning how to bill for payment (e.g., value codes, occurrence codes) should continue to be directed to your local FI or carrier. If a provider submits a claim on behalf of a beneficiary and there is an indication of MSP, but not sufficient information to disprove the existence of MSP, the claim will be investigated by the COB Contractor. This investigation will be performed with the provider or supplier that submitted the claim. MSP investigations will no longer be a function of your local FI or carrier. The goal of MSP information gathering and investigation is to identify MSP situations quickly and accurately, thus ensuring correct primary and secondary payments by the responsible party. Providers, physicians, and other suppliers benefit not only from lower administrative claims costs, but also through enhanced customer service to their Medicare patients.
Medicare Secondary Payer Auxiliary Records in HCFA’s Database
The COB Contractor will be the sole authority in ensuring the accuracy and integrity of the MSP information contained in HCFA’s database (i.e. Common Working File). Information received as a result of MSP gathering and investigation is stored on the CWF in an MSP auxiliary file. The MSP auxiliary file allows for the entry of several auxiliary records, where necessary. MSP data may be updated, as necessary, based on additional information received from external parties (e.g., beneficiaries, providers, attorneys, third party payers). Beneficiary and/or spousal changes in employment, reporting of an accident, illness, or injury, Federal program coverage changes, or any other insurance coverage information should be reported directly to the COB Contractor. HCFA also relies on providers and suppliers to ask their Medicare patients about the presence of other primary health care coverage, and to report this information when filing claims with the Medicare Program.
Contacting the COB Contractor
Effective January 1, 2001, please refer all MSP inquiries; including, the reporting of potential MSP situations, changes in a beneficiary’s insurance coverage, changes in employment, and general MSP questions/concerns to the COB Contractor. Continue to call your local FI and/or carrier regarding claims-related questions. The COB Contractor’s Customer Call Center toll free number is 1-800-999-1118 or TDD/TYY 1-800-318-8782. Customer Service Representatives are available to assist you from 8 AM to 8 PM, Monday through Friday, Eastern Standard Time, except holidays. Clip and post this section in a handy place for access by your office and billing staff.