Insurance and revenue
Coordination of benefits software that gets the payer order right.
Which plan pays first, settled before the claim is built.
Who pays first · Leo M., age 9
Mother's plan
Commercial PPO · birthday 14 March
Father's plan
Commercial HMO · birthday 2 August
- Payer already states an order
- Medicare, Medicaid or TRICARE involved
- Accident or workers' comp claim
- Court order names a plan
- Birthday rule: earlier birthday in the year pays first
Wrong payer order is one of the most common and most avoidable denial reasons. Settling it before the visit means the claim goes to the right payer the first time.
1st time
claims sent to the right payer in the right order
0
patients asked the same question twice
What coordination of benefits decides for a clinic
Coordination of benefits is the set of rules that decides which plan pays first when a patient has more than one. Bill the wrong plan first and the claim comes back denied, usually as CO-22, and the clock on timely filing keeps running while you sort it out.
The rules are not hard one at a time. The work is applying them in order to every dual-coverage patient, noticing a second plan nobody mentioned, and getting the one missing fact before the claim is built.
2care's coordination of benefits software does that work across your schedule and writes the settled order to the chart, so primary and secondary claims go out in sequence.
Where the money comes from
One $240 visit, paid by two plans and the patient.
When the order is right, the primary pays its share, the secondary insurance picks up most of what is left, and the patient owes only the remainder.
Ella M., office visit, CPT 99393
Billed
$240
Primary paid
$160
Secondary paid
$56
Patient owes
$24
How the $240 is covered
Billed in the wrong order, the first claim comes back CO-22 and the full $240 waits.
Medicare cases
Medicare secondary payer rules turn on one employer fact.
A 67 year old who still works can have Medicare as primary or secondary depending on how many people their employer has. That is the fact most charts are missing.
Robert D., age 67, two plans on file
Result
Confirmed: employer group plan primary, Medicare secondary
Order written to the chart. Medicare claim waits for the group plan's remittance.
When sources conflict
Records disagree, so the claim is held instead of guessed.
When your PMS, the payer and the patient conflict, 2care stops the claim and says exactly where the disagreement is.
COB alert, Priya S.
- Visit
- Nov 12, 10:00 AM
- Claim
- CLM-48213
- Your PMS says
- Commercial PPO primary
- Commercial PPO reports
- Other coverage, primary
- Other plan found
- Spouse's Commercial HMO
- Patient is
- Dependent on the HMO
- Claim status
- Held
- Next step
- COB form texted
Released only after staff confirm the order.
Asking the patient
A short texted form for the one missing fact.
Patients know these answers. A text with two or three plain questions gets answered.
COB questions by text
Priya S.
Text thread
Hi Priya, this is your clinic. We see two insurance plans for you. Three quick questions so we bill the right one first.
1. Which plan is through your own job: the PPO or the HMO?
PPO is mine. HMO is my husband's.
2. Are you still working at the job that gives you the PPO?
Yes, full time.
3. Is either plan COBRA or retiree coverage?
No
Answers saved word for word as a draft for staff approval.
From flag to released claims
Two days from a COB conflict to claims in the right sequence.
The whole path is logged, so an audit or a billing question has a clear answer.
Priya S., CLM-48213
Conflict detected
Nov 10, 6:00 AMPPO reports other coverage
COB form texted
SMSNov 10, 9:05 AMThree questions sent
Answers in
SMSNov 10, 12:18 PMPPO is her own, active
Order confirmed
Nov 11, 8:40 AMStaff clicked Use this order
Primary claim sent
Nov 12Commercial PPO, 837P
Secondary claim
Waits for primary 835
Secondary goes out automatically once the primary remittance posts.
Caught before the visit
Checks run ahead of the appointment, so most conflicts clear before any claim exists.
A person confirms the order
Staff approve the order with one click. 2care does the reading and asking, and the call stays with your team.
Claims leave in sequence
The primary is filed first and the secondary follows the primary's remittance, with no manual handoff in between.
Clear lines
What the COB engine settles and what it leaves to staff.
Settles
- Finding other coverage reported by payers
- Applying Medicare, Medicaid, TRICARE, accident and NAIC rules in order
- Asking the patient for missing facts by text or call
- Holding claims when records disagree
- Sending primary and secondary claims in sequence
Leaves to staff
- Overwriting the chart without staff approval
- Guessing an order when facts are missing
- Reading a custody agreement for you
- Contacting an employer on the patient's behalf
Insurance and revenue
The rest of the workflow.
Two plans, one patient
Coordination of benefits questions, answered plainly.
It works out which plan pays first when a patient has more than one, collects any missing facts from the patient, and makes sure claims go to each plan in the right order. 2care writes the confirmed order to the chart and holds claims when sources conflict.
When a child is covered as a dependent on both parents' plans and the parents are married or share custody without a court order, the plan of the parent whose birthday falls earlier in the calendar year pays first. Only month and day count, not the year of birth.
It checks whether the patient or spouse has coverage from current employment and the employer's size: 20 or more employees for working aged patients, 100 or more for disability. ESRD patients follow the 30-month coordination period. Retiree and COBRA coverage are treated as not current employment.
After the primary plan's remittance arrives. 2care builds the secondary claim with the primary's payment and adjustments attached, so the secondary insurance can process its share without asking for the primary's explanation of benefits.
The order stays at Needs answers and the claim is held. A patient call asks the same questions, and if that fails the case goes to staff.
Yes. Nothing is written to the chart until a staff member clicks Use this order, and they can choose a different order with a note explaining why.
Yes. Patients with two dental plans follow the same subscriber, dependent and birthday rules, and 2care handles them the same way.
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