Description
This unit introduces learners to the Coordination of Benefits (COB) process—an essential mechanism for determining which payer holds primary, secondary, or tertiary responsibility for patient claims. Learners will explore payer sequencing, CMS guidelines, and real-world denial scenarios to build operational competence in multi-payer claim processing.
By mastering COB verification and claim resubmission workflows, students will enhance accuracy, minimize revenue leakage, and prevent duplicate billing or underpayments across complex payer structures.
Define Coordination of Benefits (COB) and articulate its purpose in the revenue cycle.
Explain the rules for determining primary and secondary insurers, including payer hierarchy rules.
Use COB logic to resolve real-world billing scenarios with multiple insurers.
Examine how payer mix and policy overlaps impact reimbursement outcomes.
Identify and critique COB discrepancies in claims that lead to denials.
Design and implement a decision matrix for accurate COB determination and documentation.
By the end of this unit, learners will be able to:
Explain the importance of COB in ensuring accurate payment allocation across multiple payers.
Correctly identify and apply payer sequencing rules using CMS and commercial guidelines.
Interpret and apply Medicare Secondary Payer (MSP) rules.
Analyze COB-related denials to trace and correct the underlying sequencing or data entry errors.
Modify patient account details to reflect correct payer hierarchy within the EHR or billing system.
Develop a compliant COB verification and claim resubmission workflow that prevents delays and improves reimbursement integrity.
Completion of Units 2.1 (Front-End Services and Patient Intake) and 2.2 (Eligibility Verification).
Basic understanding of payer structures, claim forms (CMS-1500, UB-04), and insurance plan types.
Patient Access Representatives and Billing Specialists
Revenue Cycle Coordinators and Denial Management Staff
Payer Relations Analysts and COB Specialists
Healthcare Administration and HIM Students
Compliance Officers involved in payer audits and revenue integrity initiatives
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