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Provider Manual

Coordination of Benefits

Last Updated on August 28, 2018

Coordination of Benefits (COB)

  • If a member carries insurance through more than one insurer, Family Health Center will coordinate the benefits to ensure maximum coverage without duplication of payments.
  • The affiliated provider must submit claims to the primary carrier before submitting to Family Health Center. After a claim is processed by the primary carrier, a claim for the balance should be submitted to Family Health Center along with either the primary carrier’s Explanation of Benefits (EOB) or their electronic payment/denial information. The affiliated provider must submit the claim within 365 days from the date of service.
  • If the affiliated provider fails to comply or is unaware of the primary insurance carrier, claims for which Family Health Center is secondary will be denied using ANSI code 22. This denial reason will print on the affiliated provider’s reimbursement statement.
  • If a primary insurance is discovered after charges have been processed by Family Health Center and the primary insurance makes payment, the affiliated provider may have an overpayment. The affiliated provider should complete an adjustment request form and submit it with a copy of the original claim and a copy of the EOB from the primary insurance. Claims will be reprocessed based on the primary insurance payment. The adjustment will be reflected on the affiliated provider’s reimbursement statement.
  • If Family Health Center discovers a primary insurance after charges have been processed, Family Health Center will reverse its original payment. The adjustment will be reflected on the affiliated provider’s statement using ANSI 22.
  • If the primary insurance denies a claim because of lack of information, Family Health Center will also deny.
  • If the primary insurance denies a claim with Claim Adjustment Group Code “CO,” financial responsibility for the unpaid charge is assigned to the provider as a contractual obligation. As a secondary or tertiary payer, Security Health Plan will also deny these charges using Claim Adjustment Reason Code (CARC) 276: “Services denied by the prior payer are not covered by this payer”. Affiliated providers may not balance bill members for CARC 276 denials.
  • If the affiliated provider has any questions regarding coordination of benefits, call 715-221-9503 or 1-800-548-4831 Monday through Friday, between 8:00 a.m. and 4:30 p.m. or email shpcob@securityhealth.org

If a Family Health Center member has Medicare or another insurance, follow these instructions to ensure a claim will be processed correctly and in a timely manner.

  • Complete information must be on the CMS 1500 claim or UB-04 claim, or must be included with the electronic claim..
  • On the CMS 1500 claim, box 11d should be checked “Yes” if there is any other insurance information. If box 11d is checked “Yes”, boxes 9a – 9d on the CMS 1500 claim must be completed with the other insurance information.
  • On the UB-04 claim, field 50 should be completed if there is any other insurance information.
  • On electronic CMS 1500 or UB-04 claims, loop 2320 should include other insurance information.  
  • EOBs or electronic payment/denial information must accompany each CMS 1500 claim and UB-04 claim if other primary insurance is indicated on the claim.