The COB Challenge
Coordination of Benefits (COB) – the perpetual headache for healthcare payers. Manual processes, incomplete member questionnaires, and the eternal struggle of determining the order of benefits. The result? Delayed payments, increase in appeals such as over payment and under payment of claims, and an increase of claim pend ratio.
System Limitations
Many core claims systems do not automatically import COB information from EDI files or calculate COB amounts for you. Even with sophisticated systems, the key details — prior paid adjusted amounts, copays, coinsurance, non-payable expenses, and contractual write off amounts — often stay hidden within the complex data structure of the EDI file, causing unnecessary complications.
SymKey’s Tactical Approach
SymKey doesn’t just identify the problem; it solves it. The solution is straightforward: leveraging intelligent queries to identify claims with COB, processing them based on the client’s business requirements, and automating adjustments. No more manual hunting for information from EDI viewers or painstakingly calculating adjustments. SymKey intelligently adjusts amounts based on adjustments and financial responsibilities, streamlining the entire process.
SymKey for EZ-CAP Process Overview:
- Query EZDATAREP for Professional and Hospital EDI claim information.
- Extract COB details from 2430 SVD and CAS Segments.
- Calculate necessary adjustments on EZ-CAP claims.
- Apply Patient Responsibility as the new Contract Value and Net Pay amount.
- Assign appropriate CARC and RARC codes.
The Results
The real victory here? Relief from the laborious process of hunting down EDI adjusted amounts, calculating changes for each claim line manually. SymKey isn’t just a solution; it’s a strategic move to eliminate manual processes and inefficiencies, decrease pend ratio, reduce errors, and ensure the accurate and timely processing of COB claims.
Tired of COB complexities? Unlock efficiency with SymKey and bid farewell to payment headaches!