When a healthcare provider treats a patient who has Medicare as well as another type of health insurance, understanding the rules for Medicare Coordination of Benefits (COB) becomes essential. Improper COB handling can result in claim denials, delays, and lost revenue. This article provides a practical overview of all major COB scenarios and outlines how Medicare interacts with other insurance payers, helping healthcare providers submit clean and compliant claims.
What is Medicare Coordination of Benefits?
Coordination of Benefits (COB) refers to the process used to determine which insurance payer is responsible for paying a healthcare claim first when a patient has more than one form of coverage. In the case of Medicare, the Centers for Medicare & Medicaid Services (CMS) delegates this responsibility to the Benefits Coordination & Recovery Center (BCRC). Medicare may be the primary or secondary payer, depending on the type of additional insurance involved. Submitting claims in the wrong order often leads to rejections, overpayments, or audits, making accurate COB practices vital for healthcare providers.
Key Medicare COB Scenarios and Billing Rules
Here are the most common Medicare COB scenarios with details on how billing should be handled:
1. Medicare and Employer Group Health Plan (EGHP)
Medicare is secondary if the patient is:
- Age 65 or older and actively working or
- Covered under a working spouse’s plan, where the employer has 20 or more employees.
- Medicare is primary if the employer has fewer than 20 employees.
Always submit claims first to the employer insurance. Once processed, submit the secondary claim to Medicare with the appropriate explanation of benefits (EOB).
2. Medicare and Retiree Coverage
Medicare is primary. Retiree health insurance offered by a former employer is secondary. Common mistake in such a scenario: billing the retiree plan first. This leads to rejections or improper COB adjustment denials from Medicare.
3. Medicare and Medicaid (Dual Eligible)
Medicare is always primary. Medicaid is the payer of last resort and may cover coinsurance, deductibles, and services not covered by Medicare. Always submit claims to Medicare first. Only bill Medicaid after receiving Medicare’s remittance advice.
4. Medicare and TRICARE
For military retirees, Medicare is primary, and TRICARE for Life acts as secondary. For active-duty military members, TRICARE is primary. Note that TRICARE claims may require coordination directly with the Defense Health Agency.
5. Medicare and Marketplace (ACA) Plans
Marketplace insurance plans are not compatible with Medicare. Medicare is primary, and most ACA plans will not pay as secondary. Do not bill ACA plans as secondary if the patient has active Medicare.
6. Medicare Advantage (MA) and Other Insurance
When a patient is enrolled in a Medicare Advantage plan, that plan becomes primary to any other coverage unless otherwise specified. Providers must follow the COB rules of the MA plan, not Original Medicare. Always send the claim directly to the Medicare Advantage plan first, not to Medicare Part A/B.
7. Medicare and Workers’ Compensation / Auto Insurance
Workers’ comp and auto/no-fault insurers are always primary if the injury or condition is related to an accident or job injury. Medicare pays only if:
- The primary payer denies coverage, or
- A conditional payment is made with the intent to recover later.
Notify the BCRC when conditional payments may apply.
8. Medicare and Liability Insurance
Liability insurance (e.g., auto accidents, personal injury) is primary to Medicare. Medicare may make a conditional payment and later recover funds after the liability claim settles. Always document all payer interactions and notify BCRC of pending settlements.
How to Coordinate Benefits with Medicare
Healthcare providers play a crucial role in correct COB processing:
- Verify insurance coverage during each visit.
- Use Medicare’s HIPAA Eligibility Transaction System (HETS) to confirm COB details.
- Flag accounts with multiple insurances for manual review.
If coverage details change, patients can contact the Benefits Coordination & Recovery Center (BCRC) at đź“ž Medicare Coordination of Benefits phone number: 1-855-798-2627 (Also referred to as the Medicare COB phone number or Medicare Coordination of Benefits and Recovery phone number)
Conclusion
Mastering Medicare coordination of benefits helps healthcare providers avoid delays, reduce rework, and maintain cash flow. Understanding how Medicare interacts with other payers ensures claims are submitted correctly the first time. If you regularly bill patients with secondary insurance, having the right COB workflow in place is essential.
Frequently Asked Questions (FAQs)
Q1: Can I have Medicare and employer coverage at the same time?
- A1: Yes. In such cases, the size of the employer determines whether Medicare is primary or secondary.
Q2: What is the coordination period for Medicare?
- A2: There is no fixed coordination period. COB rules apply for the duration of overlapping coverage.
Q3: How is a patient’s Medicare Coordination of Benefits information updated?
- A3: Patients are responsible for updating their coverage details by contacting the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. This is the primary Medicare Coordination of Benefits phone number for such updates.
About Medisys
At Medisys, we help healthcare providers navigate complex Medicare COB scenarios with precision and compliance. Our team ensures that each claim reflects the correct primary and secondary payer order, minimizing the risk of denials and accelerating reimbursements. From dual eligibles to complex COB scenarios involving employer plans or TRICARE, we proactively verify insurance, apply payer-specific rules, and follow CMS guidelines to ensure clean claims every time. With Medisys, providers can trust that their Medicare billing is handled with precision and compliance. Contact us to discover how we can simplify your billing challenges.
