Third Party Liability, also known as coordination of benefits (COB), is a claim adjudication process that identifies if parties other than the system’s insurance company have primary financial responsibility for some or all of a submitted claim. Additional third-party liability or coordination of benefit information is supplied as part of the patient match through the membership module. The policy information for the member is stored in the membership data model and ordered based on the ranking that is detailed in the chapter on Member Eligibility.
The Pega Smart Claims Engine for Healthcare checks if COB information is submitted on the claim to show other coverage and how much was paid. Pega Smart Claims Engine for Healthcare then identifies whether this information is used in the adjudication of the claim, or whether the claim should set a Pend, for further exploration against the other insurer.
The following are examples of the logic used to set COB pends by the system:
- If the claim billed to pay by the payer and other insurance exists for the member that should be billed first, and the COB segments on the claim are not received, the claim sets and event code for the other insurer to pay first.
- The Pega Smart Claims Engine for Healthcare sets an event code on the claim if a COB segment is sent on the claim for an insurer that is not known by the payer in the membership system.
- The Pega Smart Claims Engine for Healthcare sets an event code on the claim if TPL information exists for the member, but when the other payer has not paid and denied the claim with an adjustment code for a specific reason. The adjustment codes that bypass the setting of the event code when the other payer has not paid can be added and extended in the decision table: SetReasonCodeToAdjGroupCode
The system looks through the claim to see if COB submitted on both the header and details to see if there are any event codes that need to set.
Currently, Pega Smart Claims Engine for Healthcare sets eleven types of pends when the COB is present on the claim.
Validating that other insurance should be billed
The SCE has a configuration in the system to perform the following functions.
- Identify where this claim fits into a COB priority matrix based on information submitted on the claim.
- See if claims for other insurance that have a higher priority than this claim have been billed correctly and are listed in the Other Insurance sections of the claim.
The first step is to use the CE_DetermineClaimPriority decision table to identify the order of priorities for this claim. Each row on this table is configured with a when statement to see if the conditions for that policy type exist. Sample when statements are delivered with the SCE and can be extended by the clients and configured into the priority order as needed.
Sample when statements are detailed below:
- IsLiabilityInsuranceClaim – Checks for Accident Indicator or OA in related causes codes.
- IsAutoInsuranceClaim – Checks for Auto Accident Indicator or AA in related causes codes.
- IsWorkersCompensationClaim – Checks for Employment Indicator or EM in related causes codes.
- IsBlackLungClaim – Checks for existence of Black lung diagnosis on CE_BlackLungDiagnosis table
- IsDentalClaim – Checks to see if the claim form type is D (Dental)
Once the order of other insurance on the claim is known, the CE_PrioritizeContracts data transform is used to match the Other insurance on the claim to the contracts, look for gaps and set the appropriate event codes based on those gaps.
The event codes associated with the Other Insurance and COB Cost Avoidance are detailed below:
|External Payer exists without COB. Where other party liability insurance information exists for the member and the other insurance is a higher priority payer and the COB segments for that payer on the claim are not received.
|Claim COB Payer paid amount is missing. The other payer on the claim does not have a paid amount present.
|Claim COB Other Payer name is missing. The other payer on the claim doesn’t have a name.
|Claim Product Category doesn’t match a Patient Policy. The claim and COB information submitted on the claim doesn’t match an existing policy for the Member.
|The COB Subscriber name on the claim is different than the one found in the system.
|The COB Subscriber address on the claim is different than the one in the system
|Invalid Other Insurance Subscriber on the claim
|Other subscriber doesn’t have a policy. There is COB information on the claim, but it doesn’t match a known policy in the system. This is unknown claim COB.
|No COB on the Claim and No Patient Policy. There is no COB on the claim and no existing Patient Policy information, but the claim meets the criteria to deny for COB.
|Subscriber does not have a contract with other payer on the claim
|Other Subscriber does not have a Payer associated with the Contract
|Other Subscriber does not match Payer. When the other insurance is the primary payer and there is a COB segment on the claim, but the other payer information doesn’t match for the subscriber in our system.
|Other Payer Paid Zero & Invalid Reason. The other payer paid zero and the adjustment codes submitted with the other payer payment are not a valid reason for a zero payment.
|Payer Responsibility Sequence not selected on COB. The payer responsibility sequence was not entered in the COB section on the claim.
|Invalid Payer Responsibility Sequence. The payer responsibility sequence on the claim is invalid.