COB Segment

Field #

Field Name

Possible Value or Explanation of Field

337-4C

Other Payer Count

Indicates how many other payers are being submitted; automatically generated based on COB segment

338-5C

OP Coverage Type 1

Code identifying the type of other payer; blank - not specified, 01 - Primary, 02 - Secondary, and so forth. Located in the COB tab of the main processing screen

339-6C

OP ID Qualifier 1

Code indicating the Other Payer ID qualifier; located in the COB tab of the main processing screen

340-7C

OP ID 1

Other Payer ID number, must correctly correspond to the ID selected above; located in the COB tab of the main processing screen

443-E8

OP Date 1

Payment or rejection date of the claim submitted to other payer, generated automatically based on that claim

993-A7

Internal Control Number 1

Number assigned by processor to identify an adjudicated claim when supplied in payer to payer COB only; located in the COB tab of the main processing screen

341-HB

OPAP Count 1

Total of OP amounts paid; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen

342-HC

OPAP Qualifier 1.1

The OP amount paid qualifier indicating type of payment taken; located in the COB tab of the main processing screen

431-DV

OPAP Amount 1.1

The OP amount paid itself based on qualifier above; located in the COB tab of the main processing screen

353-NR

OPPRA Count 1

Total of OP patient responsibility amounts paid; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen

351-NP

OPPRA Qualifier 1.1

The OP patient responsibility amount paid qualifier indicating type of payment requested; located in the COB tab of the main processing screen

352-NQ

OPPRA Amount 1.1

The OP patient responsibility amount paid itself based on qualifier above; located in the COB tab of the main processing screen

392-MU

Benefit Stage Count 1

Total of the number of benefit stage occurrences; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen

393-MV

Benefit Stage Qualifier 1.1

Blank, 01- Deductible, 02- Initial Benefit, 03- Coverage Gap, 04-Catastrophic Coverage, 50-Not paid under Part D but paid under Part C, 60- Not paid under Part D but paid as or under supplemental benefit only, 61- Part D drug not paid by Part D plan benefit, paid as or under a co-administered insured benefit only, 62- Non-Part D/non-qualified drug not paid by Part D plan benefit. Paid as or under a co-administered benefit only, 70- Part D drug not paid by Part D plan benefit, paid by the beneficiary under plan-sponsored negotiated pricing, 80- Non-Part D/non-qualified drug not paid by Part D plan benefit, hospice benefit, or any other component of Medicare; paid by the beneficiary under plan-sponsored negotiated pricing, 90- Enhance or OTC drug (PDE value of E/O) not applicable to the Part D drug spend, but is covered by the Part D plan; located in the COB tab of the main processing screen

394-MW

Benefit Stage Amount 1.1

The actual benefit stage amount as indicated by the qualifier above; located in the COB tab of the main processing screen

471-5E

OP Reject Count 1

The total of the number of other payer rejections; this field automatically adds the populated lines in the COB segment, located in the COB tab of the main processing screen

472-6E

OP Reject Codes 1.1

The other payer rejection code itself, based on the qualifier above; located in the COB tab of the main processing screen