Coordination of benefits (COB)

Yes, you can send Aetna secondary claims electronically!

Since we support the HIPAA standard for electronic batch claims submission, we accept electronically submitted coordination of benefits (COB) claims. You can submit COB claims directly from:

• A provider who has received a remittance advice from the previous payer (provider-to-payer COB)
• The previous payer (Payer-to-payer COB)

Determining which plan is primary

When a patient comes into your office, start by submitting an electronic eligibility and benefits request. Our response will tell you:

• whether the patient is eligible
• important financial details such as copayments, deductibles and coinsurance and any remaining amounts
• other coverage for the member, if applicable
• which plan is primary

Look for information about other insurance plans in the COB section of our benefits response. No matter what website you use, we’ll return the COB information we have on file. You can then use the information in the response to submit your primary claim to the correct insurance plan.

We participate in COB Smart™, a CAQH® Solution. For more information on COB Smart and to see a list of markets as they go live starting in fall 2013, please visit the Council for Affordable Quality Healthcare’s (CAQH) website.For tips on successfully submitting eligibility requests, visit our Electronic transactions and tools help documents page.

Tips for submitting coordination of benefits claims

To submit COB claims, your practice management system/data entry process and your clearinghouse must be able to:

• Create or forward claims in the full HIPAA standard format (837) or in a format that contains equivalent information and includes necessary COB fields.
• Include payment information received from the primary payer's HIPAA standard electronic remittance advice (ERA) or by converting the primary payer's paper Explanation of Benefits (EOB) into the standard coding used in an ERA (see section on "Converting information" for more details).

Types of COB claims that can be sent electronically

• Commercial insurance claims where another payer is primary and Aetna is secondary.
• Medicare primary claims when Medicare* hasn't already forwarded us their claim and payment information.

* Aetna can accept both Medicare Part A and Part B claims electronically from Medicare. If the Medicare ERA or Explanation of Payment (EOP) contains an "MA18" or "N89" remark code, the Medicare carrier has automatically sent us youir claim. In these cases, you don't have to send us a Medicare Primary COB claim.

Payment information required for commercial electronic COB claims  

• Adjustment amounts - at both claim level and service line level (if available)
• Adjustment reasons - contractual obligation, deductible, coinsurance, etc.
• Primary payer paid amount - at both claim level and service line level (if available)

Payment information required for Medicare primary electronic COB claims

• Adjustment amounts - at both claim level and service line level (if available)
• Adjustment reasons - contractual obligation, deductible, coinsurance, etc.
• Medicare paid amount - at both claim level and service line level (if available)
• Medicare acceptance of assignment

Converting information from paper EOBs into industry-standard ERA codes  

When working with a paper EOB, there's an "electronic" way to let us know how the primary payer adjudicated the claim. By using HIPAA-approved code values, you can convert payment information received from the primary payer by paper and transmit it electronically.

• Adjustment Group Code - This code tells us who (the patient or the provider) is responsible for any adjustments made.
• Adjustment Reason Code - This code explains what type of adjustment was made (for example, deductible, coinsurance, write-off amount, etc.).

Note: Your paper remittance may already contain standard code values. If so, please use the codes furnished by the primary payer.

For a comprehensive listing of Adjustment Group and Adjustment Reason codes, please review Adjustment Reason Code and Adjustment Group Code Categorization Table  (PDF, 122 KB). Or, visit the Washington Publishing Company at www.wpc-edi.com to view all HIPAA code lists.

For more information  

You can send us an e-mail. Simply select "Contact Us" at the bottom of this page.

Or, contact the practice management support team and/or the clearinghouse you use to submit your electronic claims. Ask them if they are ready to transmit electronic COB claims. They may have their own guidelines or tips about submitting COB claims.

Supporting Documents

These documents provide information on the process of submitting electronic claims.

COB Data Fields  (PDF, 147 KB) provides you with the full content of the fields required to submit electronic COB claims. This document tells you all of the needed data elements (e.g. loops, segments) found in the ASC X12N 837 Implementation Guide for submission in Version 5010.

Adjustment Reason and Adjustment Group Codes Categorization Table  (PDF, 122 KB) helps you convert primary payment information received on a paper EOB into industry standard coding.

HIPAA Implementation Guide shows information on the secondary COB claims process, and you can buy it through the Accredited Standards Committee.