Setup

We provide options in the Pharmacy Setup screen for how a pharmacy can set up their split billing.

• COB Billing Prompt Type: The available options are All Plans or Only Linked Plan

• Show COB Billing Prompt When: The available options are User Will Prompt, Auto-Prompt When Copay > 0.00 or Auto-Prompt Always

The Show COB Billing Prompt option tells the program when to prompt the user for split billing. This option does different things depending on the value of the COB Billing Prompt Type option.

COB Billing Prompt Type is set to All Plans:

COB Billing Prompt Type is set to Only Linked Plan:

Linking a Plan

A “linked plan” is when you indicate a “Secondary Plan” for a patient in the Patient Insurance screen. In this instance, the primary plan would be “EPIC” and the linked plan would be “MCD”. In most cases, when you indicate a secondary plan, you will also enter values for the “OP ID Qualifier” and the “OP ID”.

Split Billing from Claim Response Screen

When billing a claim, if there is a plan linked to the primary insurance, then the program will prompt the user to ask if they want to bill the secondary plan. If the user chooses “Yes”, then the BestRx program will automatically populate the COB info for the prescription and proceed to bill the secondary plan.

After billing the primary plan, if the claim was paid and there is a copay or if the claim was rejected, the program will ask the user if they want to bill a secondary plan. It will display a list of all plans for the patient and the user can choose which plan they want to bill.

If the patient has a linked plan on the Patient Insurance screen for the primary plan, then the linked plan will be the first option and displayed in bold. This will let the user know this is a linked plan. The rest of the plans will be displayed in the same order they appear on the Patient Insurance screen for this patient.

In most cases, you don’t have to do anything with the “OP ID Qualifier” and “OP ID” fields.. The program will attempt to automatically determine those values and assign them to the COB tab. If the user want to enter a value that is different from the ones that will be automatically generated, then they can change them from here.

Note: If the claim is being billed for the secondary plan, then the program will prompt to bill another plan only if there is a plan linked to the secondary plan.

Adding a New Plan from the Claim Response

From here the user can also add an new plan to the patient’s profile. If the user chooses this option, then a screen will pop up where the user can enter some basic plan information. If they need to enter more detailed information, the user will need to access the Patient screen and enter the plan the normal way.

Now, there is a Split Bill button on the bottom of the Claim Response screen. This button will be visible for all claims. The user can click this button at any time to display the little panel that allows you to choose what plan they want to split bill to.

Insurance Plan Split Billing Settings

On the Insurance Plan screen, when you click the COB / Dual Billing tab you will see the following options for Coordination of Benefits/Dual Billing Settings. In this document, I will explain how each of these fields work.

Send Other Payer Amount Paid (OPAP) Info

If this value is set to “Yes” then the OPAP fields will be sent to the secondary insurance. The OPAP fields refer to the fields circled in the image below. These fields let the secondary insurance company know how much the primary insurance paid. If the patient was set up for dual billing prior to sending the claim to the primary insurance, these fields will populate automatically.

Most of the time the only value that will need to be reported is the 07-Drug Benefit. The Drug Benefit will be equal to the Cost+Dispensing Fee that the primary insurance actually paid, not counting the copay. In the example below, the primary insurance approved a total of 63.99 but they only paid 53.99 because 10.00 of that was a copay. Therefore the OP Amount Paid would be 53.99.

In some instances other values besides the 07-Drug Benefit will be required. If the primary insurance paid a tax, then you would have to report the 10-Sales Tax value or if a compounding fee was paid you would have to report the 09-Compound Preparation Cost value. If these values are required, they will be available on the response screen of the primary insurance.

The sum of all the OPAP values should be equal to the total amount actually paid by the primary insurance, which does not include the copay.

Anytime OPAP values are sent, the Other Coverage Code on the main screen should be either 02 (approved claim where primary paid something), 03 (rejected by primary) or 04 (approved claim where primary did NOT pay anything).

Send OP Patient Responsibility Amount (OPPRA) Info

If this value is set to “Yes” then the OPPRA fields will be sent to the secondary insurance. The OPPRA fields refer to the fields circled in the image below. These fields let the secondary insurance company know how much the patient still owes for the prescription and why. If the patient was set up for dual billing prior to sending the claim to the primary insurance, these fields will populate automatically.

The values that need to be sent will be displayed on the response screen for the primary insurance. Some insurances want to know each individual component of the Patient Pay Amount, others only want to know the total Patient Pay Amount, and others will want to know both. This is explained in further detail on the following pages.

When OPPRA values are sent, if the OPAP values were also sent, then the Other Coverage Code on the main screen should be 02 (approved claim where primary paid something), 03 (rejected by primary) or 04 (approved claim where primary did NOT pay anything). But if the OPAP values are NOT sent, then the Other Coverage Code should be either 03 (rejected by primary) or 08 (approved by primary).

Send OPPRA Component Amounts

The total Patient Pay Amount could consist of many different values. The values of 05-Amount of Copay and 01-Amount Applied to Periodic Deductible are the most common values, but other values such as 07-Amount of Coinsurance or 03-Amount Attributed to Sales Tax or others may also be in play. Click on the drop-down box on the COB screen to see all the possible values.

If an insurance company requires that the individual components of the Patient Pay Amount be reported, then you must report the necessary values. These values can be found on the response screen of the primary insurance. If the only thing you see on the response screen is the total Patient Pay Amount, it means the only component is the 05-Amount of Copay. Since that is by far the most frequent reason for a Patient Pay Amount, to avoid confusion we do not list it separately. But if the Patient Pay Amount consists of anything besides the Copay or there are multiple components to a Patient Pay Amount we will list the individial components along with the total Patient Pay Amount on the response screen. If the patient was set up for dual billing prior to billing the primary insurance, these fields will populate automatically.

Example Claim Responses

Screenshot with Copay as the only component of Patient Pay Amount

Screenshot with only one Patient Pay component that is not a Copay

Screenshot with multiple Patient Pay components

Send OPPRA Total Amount

When an insurance company requires that the Total Patient Pay Amount be sent in the OPPRA fields, you would use the value of 06-Patient Pay Amount and enter the value there. This value can be found on the response screen of the primary insurance plan. If the patient was set up for dual billing prior to billing the primary insurance, this field will populate automatically.

If the component values of the Patient Pay amount are also being sent, then the sum of the Component Values should equal the Total Patient Pay Amount value. For example, if the primary insurance said that the Copay was 10.00, the Deductible was 25.00 and the Processor Fee was 2.00, then for the OPPRA fields you would send the values below. Note how the sum of the component values is equal to the Total Patient Pay Amount.

• 25.00 (01 - Amount Applied to Periodic Deductible)

• 10.00 (05 – Amount of Copay)

• 2.00 (13 – Amount Attributed to Processor Fee)

• 37.00 (06 – Patient Pay Amount)

In the example above, if the secondary insurance did not require the component values, then the only value that would have been sent is the 37.00 (06 – Patient Pay Amount).

Send Benefit Stage Info

If the primary insurance is a Medicare Part D or Medicare Part B claim, the secondary insurance may require that the Benefit Stage info be sent. The Benefit Stage Info lets the secondary insurance know how the primary insurance came up with the total amount they approved for the claim. This information can be found on the response screen of the primary insurance claim. If the patient was set up for dual billing prior to billing the primary insurance, these fields will populate automaticallly.

The Benefit Stage Info cannot be sent on its own. It must be accompanied by either the OPAP info, OPPRA info, or both. If both the OPAP and OPPRA info are sent, then theoretically the sum of the Benefit Stage values should be equal to the sum of the OPAP values plus the sum of the OPPRA values (excluding the 06-Patient Pay Amount value if both component and total values are sent).

If the primary insurance company does not provide the Benefit Stage information in their claim response, it is impossible for us to send that information to the secondary insurance. We can not make any guesses or assumptions about what the correct Benefit Stage values might be. If the secondary insurance absolutely needs this information and the primary insurance won’t provide it, we would have to get on the phone with the insurance companies to figure out a solution. But so far this situation has not come up and hopefully it never will.

The Other Coverage Code value would be dependent on whether the OPAP or OPPRA values are being sent along with the Benefit Stage Info. See the sections for OPAP info and OPPRA info for more details.

A screenshot of the COB screen containing Benefit Stage information along with the Response screen that led that situation are provided below.

Response Screen for claim with Benefit Stage Info

Send Payment Info for Rejected Claims

This option comes into play when a claim is rejected and the secondary insurance is one that requires the OPAP info. Some plans will require that you send a value of 0.00 for 07-Drug Benefit while other plans will require that you leave those fields completely blank. If the Send Payment Info for Rejected Claims option is set to Yes, then we will send the value of 0.00. If the option is set to No, we will not send any OPAP values.

For secondary plans that require OPPRA values, currently my understanding is that we don’t send any OPPRA values if the primary insurance rejected the claim. This is because since the claim was rejected, it is impossible for the primary insurance to have returned any Patient Pay Amount values in the claim response.

For all instances where the primary plan rejected the claim, the Reject Codes should be provided to the secondary insurance so they know why the claim was rejected. These values can be found on the response screen of the primary insurance. If the patient was set up for dual billing prior to billing the primary insurance, these fields will populate automatically.

Send COB Info on Reversals

When reversing secondary claims, some insurance companies require that we send the OP Coverage Type from the COB segment to acknowledge the fact that we know we are reversing a secondary claim. Some insurance plans do not want the COB segment to be sent at all on claim reversals and will reject the reversal if that information is sent. Most insurance plans don’t care whether we send that information. They don’t require it and if we do send it, they will just ignore it.

For the insurance plans that do require the COB info for reversing secondary claims, make sure this option is set to Yes. For the plans that absolutely do not want it, make sure the option is set to No.

For the insurance plans that do require the COB info for reversing secondary claims, it is important that when reversing those claims that the secondary insurance be reversed before reversing the primary insurance. This is because when the primary insurance is reversed, the COB information will automatically be deleted. So if you attempt to reverse a secondary insurance after reversing a primary insurance, the secondary insurance won’t be able to find the COB info to send in the claim reversal.

In a situation where the primary insurance is accidentally reversed before the secondary insurance, go the the COB tab and enter in some dummy COB info for the primary plan. All you need to enter is the primary plan from the drop-down box and the OP Coverage Type. Then go ahead and reverse the secondary insurance, the claim reversal should go through. After that, be sure to delete the dummy information from the COB tab otherwise they will have trouble if they need to bill this claim again.

Other Notes About COB Billing

• For the OPAP values, the value of 08 – Sum of All Reimbursement should not be sent for D.0 claims. That value was the default in NCPDP version 5.1, but it has been retired for NCPDP version D.0 and if sent, will most likely result in a rejection or a claim that does not pay the proper amount. That value will remain in the drop-down box for the time being since not all insurances will be ready for version D.0, but sometime in the near future that value will be removed from the drop-down box.

• The information about what Other Coverage Codes should be used in certain situations is what was provided to us in the NCPDP seminars and tutorials. Those are the guidelines that insurance companies should follow and so far from what I’ve observed insurance companies are obliging by those rules. But don’t be surprised if you run into an insurance company that does its own thing and requires an Other Coverage Code that goes against those guidelines.

• The Other Coverage Code values of 05, 06, and 07 have been eliminated from NCPDP version D.0 and we will soon remove them from the drop-down box. These fields were never really used in version 5.1 either so this will not cause any issues for anyone.

• For version D.0, the COB segment is now required for all claims being billed to a secondary insurance. In version 5.1, there were certain plans that did not want the COB segment if the Other Coverage Code was 08, but the new rules require it. Let’s hope that those insurance companies oblige by the new rules.