Processing Claims for Coordination of Benefits (COB)

After a COB order is invoiced, the primary and secondary claims are created. The primary claim is automatically set to Ready to Bill status and the secondary claim is set to On Hold status.

1. Process the primary claim as you normally would.

   The secondary claim remains in On Hold status.

2. After you receive payment for the primary claim, set the status of the secondary claim to Ready to Bill Carrier and process it as you normally would.

Coordination of Benefits claims where the primary insurance is medical and the secondary insurance is VSP are set to On Hold status after invoicing and you must manually edit the claim before it can be submitted.

1. Create and invoice the order.

   The VSP secondary claim is created and the status is set to On Hold.

2. Go to Claim Management and search for the claim.

   The Claims Processing screen displays a list of your search results.

3. Locate the VSP secondary claim in the list and select Edit Claim from the Action drop-down list.

   The claim opens.

4. Under Services Rendered, enter information from the primary insurance claim in the following fields:

   • Other Ins Allowed - Enter the allowed amount for the primary insurance

   • Other Ins Paid - Enter the amount the primary insurance paid on the claim

   • Other Ins Patient Resp - Enter the Patient Responsibility amount from the primary insurance claim

   • Denied or Paid Reason - Select the reason provided by the primary insurance carrier for denying or paying the claim. The options are:

     • Bundled Service: Payment for this service is included in the reimbursement of another billed service or procedure.

     • Capitation: Claim was denied due to capitation (a uniform per capita fee).

     • Deductible: Service was applied to the deductible and paid $0.

     • Max Allowance Met: Maximum allowance was met and paid $0.

     • Not Covered: Claim was denied because the patient was not covered by the primary insurance on the date of the service or services.

     • Timely Filing: Claim was denied due to untimely filing.

5. Click Save.

   The change is saved and the Process Claims window returns to your search results.

6. Set the claim status to ready to bill. See Setting the Claim Status to Ready to Bill for instructions.

For orders with VSP as both the primary and secondary insurance, Encompass automatically processes the claim as a VSP Coordination of Benefits submission.

This means that:

• Encompass creates two claims in Claims Management.

• Only one claim is sent to Eyefinity.com.

• The secondary (unsent) claim is automatically placed in Billed status and is available for reconciliation when you receive your VSP payment.

A VSP Coordination of Benefits Secondary Authorization Number field in the Edit Claim window autopopulates with the secondary VSP authorization number applied to your order. The claim for the primary insurance is sent electronically to VSP with Box 11D automatically marked No to process your coordination of benefits and meet VSP’s requirement for Coordination of Benefits claim submission.