Subject	Coordination of benefits and balance billing
Source	AAOMS Newsletter
Publication	Coding Corner Sept/Oct. 2009
Effective Date	Sep 1, 2009
Publish Date	Sep 1, 2009

Coordination of benefits and balance billing

Coordination of benefits

Coordination of Benefits (COB) is a clause in an insurance policy to prevent duplication of payment. Because the specialty of OMS is unique in that some services are covered by medical insurance, some by dental insurance, and some by both, coordination of benefits can be a bit complex.

For example, in the case of a minor patient covered under both his/her mother's and father's medical and dental insurance, there can often be four different insurance carriers with which an office need file. Of course, it is never appropriate to submit to more than one carrier for the same service at the same time, so it is important to determine the order of benefits, if and when possible.

 Order of benefits determination

When a patient has dual coverage, coverage by his or her employer's insurance and coverage by a spouse's plan, the patient's employer's insurance is typically primary. When dealing with minors who are insured by both parents, the order of benefits is often determined by one of two rules. The birthday rule is most commonly used in determining primary responsibility for claims payment by insurance plans. When a child is covered by both parents under two separate plans and both plans follow the birthday rule, the primary plan will be the plan of the parent whose birth date (month and date, not year) falls earlier in the year. The gender rule on the other hand states that when a child is covered by both parents under two separate plans, and both plans go by the gender rule, the plan of the father is considered primary. There are 41 states that have coordination of benefit laws or regulations. All of these states have replaced the gender rule and now require use of the birthday rule. Those states without this requirement are Alaska, Washington D.C., Hawaii, Maine, Maryland, Mississippi, Nevada, New Mexico, Pennsylvania and Vermont.

As mentioned previously, coordination of benefits can often be even more complicated for those dealing with the specialty of oral and maxillofacial surgery as there is often coverage under both medical and dental insurance. While there is no official rule of thumb as to whether to first file to medical or first file to dental, it is recommended that one contact each carrier before submitting claims to verify the order of benefits. This should eliminate payment delay since the claim is submitted to the correct insurer from the start. When two carriers do not coordinate with each other one must consider the nature of the procedure/condition or the patient's benefit limitations when determining which to bill first.