EDI Coordination of Benefits

EDI Coordination of Benefits Basics For Celerian Group Company Medicare Contractors

EDI Coordination of Benefits program purposes are to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits. The BCRC (Benefits Coordination & Recovery Center) consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The BCRC does not process claims, nor does it handle any mistaken payment recoveries or claims specific inquiries. The Medicare carriers are responsible for processing claims submitted for primary or secondary payment.

CMS implemented the Coordination of Benefits Agreement (COBA), which states that the Benefits Coordination and Recovery Center will process all claims crossovers. Government Health Incorporated (GHI) is the contractor selected by CMS.

An eligibility file is sent from the Trading Partner (supplemental insurance company) to the BCRC. The file contains data to identify the Medicare ID number and claims criteria, specified by the Trading Partner, for crossovers. Each Trading Partner is issued a COBA ID. The COBA ID and eligibility file data, along with information specific to that trading partner, are stored in Medicare’s Common Working File (CWF). When claims are processed, CWF compares each COB trading partner’s claims selection criteria against the Medicare claims. If the claim matches the Trading Partner’s claims criteria and the Medicare ID number in their eligibility file, the claim information is automatically forwarded to the Trading Partner, via an electronic file.

Contact the BCRC to:

  • Report employment changes, or any other insurance coverage information.
  • Report a liability, auto/no-fault, or workers compensation case.
  • Ask general Medicare Secondary Payer (MSP) questions/ concerns.
  • Ask questions regarding Medicare Secondary Development (MSP) letters and questionnaires.

Contact your local Medicare intermediary or carrier to:

  • Answer your questions regarding Medicare claim or service denials and adjustments.
  • Answer your questions concerning how to bill for payment.
  • Process claims for primary or secondary payment.
  • Accept the return of inappropriate Medicare payment.

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