COB - General Guidance

In support of COB, much more detailed information about prior adjudication results will be available in downstream claims. Today, only a prior paid amount is available. The additional information will be beneficial as it will support more precise adjudication and fewer audits and clawbacks.

Following are some guidelines for Adjudicators and POS vendors

Coverage Type

The coverage type will be returned on the claim response. This definitively states the coverage type that was used for adjudication, and removes any guess work from the Pharmacist. This is a key field in determining COB Order and will be pased on to downstream carriers which allows them to determine the COB order using source data.

Coverage Order

Guidelines will soon be published to vendors to assist in determine COB order based on the coverage type. TBD

Additional Pertinent Information for Downstream Payors

Today, additional key data is passed on as messages in the claim response. The POS system, then transposes the data and moves it into the Special Auth field in the downstream request. This process is cumbersome and is potentially error prone.

In the FHIR standard, this information will be passed on in the *** field.

Known use cases :

  1. BC Codes: The vendor interprets/passes on to secondary in this field. Returned from BC, in equivalent of CPHA message lines (4 fields/Yes or No) – passed on to Pacific blue in the special auth field - D.64.03

  2. RAMQ vendor logic: If RAMQ paid, then proceed with secondary, assuming it was paid under special auth RAMQ. Note: RAMQ look at passing definitive information that this was paid under special auth

Disposition

The disposition on a claim response is a key piece of information used by downstream payors. It will be passed on to downstream claims.

Adjudicator Guidelines for Setting the Disposition

  1. Adjudicators should return “accepted” in the disposition, IF the claim has been fully adjudicated. Note: Plan may pay zero dollars
  2. Adjudicators should return “rejected” when they are unable to fully adjudicate the claim.

Pharmacist Choice when receiving a REJECTED Disposition
When receiving a REJECTED status, the Pharmacist MUST decide to:

  1. retry claim with different data. In this case secondary payor will see ONLY the second submission. No history of the rejected claim will be passed on to the secondary
  2. cancel the prescription, eg try different drug, or cancel if patient doesn’t want the rx. In this case, the secondary payor will not receive the claim
  3. skip the plan entirely and move to secondary payor. In this case the secondary will receive the claim with prior results, disposition = REJECTED, with the results, eg error code + zero payment. Adjudicators must look at the error codes when rejected status is received.

Adjudicator Guidance on Error Codes

Downstream adjudicators will now recieve full adjudication details from upstream claim responses. This incldues Error Codes. Some prior plan error codes (eg Provincial Health Number error) may result in a clawback. If the new prior plan error code is NOT accounted for during adjudication, it may be identified post-audit resulting in a clawback.

As such, Adjudicators should focus on key “reject” codes that will impact adjudication and account for this in their adjudication logic where possible. The more logic that is implemeneted, the fewer post-audit clawbacks.