Benefit coordination

Secondary claims to be automatically processed

When a member has two active health plans with Regence, the member is considered to have secondary (or dual) coverage. Currently, we manually copy the information from the primary claim into the secondary claim for processing.

Beginning in July 2022, once the primary claim has finished processing, we will automatically copy the primary claim into the secondary claim for processing. This will expedite processing for most secondary claims.

  • Please allow 30 days from the date the claim processed on the primary plan to be transferred and processed to the secondary. You can check the status of your claims on Availity Essentials.
  • You may see denials for claims that have already been processed (e.g., duplicate claims).
  • This impacts medical and dental claims.

Coordination of benefits

Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under, while ensuring that the total combined payment from all sources is not more than the total charge for the services provided.

When your patient has coverage under two or more payers, the primary plan will pay benefits first, with secondary and tertiary plans considering any remaining unpaid, eligible balances. When BridgeSpan is the secondary or tertiary plan, you should submit the claim to the primary plan first. When you have received a claims processing voucher from the primary plan, please submit the claim with the primary and/or secondary information electronically to us, identifying all insurance coverage information on each claim.

Coordination of Benefits (COB) claims must be submitted within 30 months from the original process date.

Electronic submission of COB information

We require electronic submission of COB claims using standard Health Insurance Portability and Accountability Act (HIPAA), American National Standards Institute (ANSI) formats for both institutional and professional COB claims. This applies to all BridgeSpan products.

To ensure electronic COB claims are processed correctly, complete all other insurance fields and use the submission guidelines in the Implementation Guide (IG) Registry, including:

  • Amount paid
  • Patient balance
  • Amount the other carrier approved

Please ensure all COB claims are submitted with the appropriate Claim Adjustment Reason Code and corresponding Group Code.

Claim Adjustment Reason Codes and Claim Adjustment Group Codes are used in COB transactions to:

  • Assign responsibility for the adjustment amount
  • Communicate how a claim or service line was paid

When submitting an electronic claim to a secondary payer, it must include the two alpha character Claim Adjustment Group Code followed by the numeric Claim Adjustment Reason Code. The alpha characters explain who is responsible for the adjusted amount, and the numeric value provides a description of the adjustment amount (e.g., PR1, CO45).

We recently identified provider billing discrepancies regarding the Claim Adjustment Reason Codes and Group Code compatibility on claims.

The discrepancies include:

  • Billing claim adjustment group code Contractual Obligation (CO) in conjunction with claim adjustment reason codes that indicate the amount is patient responsibility (e.g., deductible, copayment or coinsurance.) Note: Contractual Obligation (CO) indicates provider responsibility and Patient Responsibility (PR) indicates the member is responsible for the charges.

Claim Adjustment Reason Codes and Group Code discrepancies will result in:

  • Holding the member or provider liable in error
  • Over or under payment by the secondary insurance carrier
  • Holding the member or provider liable for the incorrect amount

View Claim Adjustment Reason Codes and Group Code indicators on the Washington Publishing Company website.

If you have questions about submitting electronic COB claims, please contact your software vendor or software support.

Completion of a member COB questionnaire

Your patient should complete our member COB questionnaire when covered by more than one health insurance policy. This will help us process claims correctly. This form is available on the BridgeSpan Health member website.

Note: The member must complete and sign the form.

The completed form should be sent to the address on the member card.

Other party liability and subrogation

A claim could be held for possible other party liability review (OPL) for multiple reasons. Reasons may include:

  • Services related to a work or auto accident
  • Services related to a known injury or accident
  • Combination of dollar amount and diagnosis code billed
  • Services related by body area to an open or ongoing investigation
  • Accident indicator on claim of auto, work, or work related auto accident

Note: This list is a general informational and not all inclusive.

If a claim is held for accident information from the member, the member needs to follow directions indicated on the letter he or she received from us or from our contracted vendor. This will consist of either an incident report, or a letter to call our vendor to provide information about the claim that is considered a potentially a third-party situation.

When an accident investigation is created, claims related to those services will pend in our claims system for up to 25 days. If the information is not received within 25 days, the investigation will close with the claim remark indicating information is required from the member. The closed claim will become member responsibility.

It is possible that an accident investigation has already been initiated and the submitted claim is related to information we already have a pended investigation on file. In this situation the claim will be attached to the pended accident investigation and held until requested information has been received or the 25 day time period is met with no information being received.

Note: The 25 days limit commences from the day the investigation is created in our system.

Based on the claim denial reason the member may need to either:

  • Contact our trusted vendor to provide the requested incident report information (reason codes O3X, O4J, O4K, O3W, O4G, O4H, O39, O4P, O4N)
    • If the member contacts Customer Service, he or she will be asked to contact the vendor directly, if he or she has not already done so.
    • If the member has contacted the vendor first and then contacts our Customer Service, he or she will be transferred to the OPL department.
  • Complete and return the incident report to the Health Plan (if reason code is O1V, O3D or O1D)

    • If you have questions, contact the Provider Contact Center at the phone number indicated on the back of the member card

The claim closure codes, including those above, will help determine how the member needs to return the required information. The member can contact Customer Service with questions or he or she can complete an Incident Report on our member website.