Introduction

Third-party liability (TPL) or Coordination of Benefits (COB) is when another insurer or program is responsible for medical costs. This entity may pay for all or part of the cost of the claim. When this occurs, the process is known as TPL or COB.

Pega Smart Claims Engine for Healthcare provides comprehensive analysis and editing methodologies to identify potentially liable third-party claims, properly avoid payments for services when another insurer is liable for payment and recover payments from liable third parties.

The configuration of the TPL Edits is in the CE_TPLEdits collection rules under the application configuration.

This collection rule currently processes two types of TPL claim edits:

• Institutional and Professional subrogation edits
• COB payer edits