Split Billing
- Anthony Campana
- jorge.mandujano
- 1 Overview
- 2 Setup
- 3 Linking a Plan
- 4 Split Billing from Claim Response Screen
- 5 Insurance Plan Split Billing Settings
- 5.1 Auto-Learn COB Settings
- 5.2 Send Other Payer Amount Paid (OPAP - Amount Paid by Insurance) Info & Combinations
- 5.3 Send OP Patient Responsibility Amount (OPPRA - Patient Pay Amount) Info & Combinations
- 5.4 Send OPPRA Component Amounts
- 5.5 Send OPPRA Total Amount
- 5.6 Send Benefit Stage Info (Benefit Stage Amount/Qual)
- 5.7 Send Payment Info for Rejected Claims
- 5.8 Send COB Info on Reversals
- 5.9 Claim Response Component Examples
- 5.10 Other Notes About COB Billing
Overview
This article provides an overview of how Split Billing works in BestRx, focusing on COB (Coordination of Benefits).
When billing prescriptions to multiple insurance plans (primary and secondary), the process ensures that claims are handled correctly. The primary claim is processed first, and if there’s a copay or rejection, the system prompts for secondary billing. BestRx includes settings to customize when and how these prompts occur, such as auto-prompting based on copay amounts or user actions.
Please note: Always reverse claims from the secondary insurance first, then the primary when split billing.
Do not alter any information on Rx Processing or COB screen before reversing, as the claim reversal needs the original transmitted data.
Setup
The Pharmacy Setup screen allows pharmacies to configure their split billing options.
File K. Pharmacy Setup Misc. (page 2)
Pharmacy Setup - Coordination of Benefits Settings
COB Billing Prompt Type: Available options are All Plans and Only Linked Plans.
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:
User Will Prompt: If there is a linked plan, the program will automatically prompt the user to split bill. If there is no linked plan, then the user will have to click the Split Bill button if they want to bill another plan.
Auto-Prompt when Copay > 0.00: The program will automatically prompt the user to split-bill if the copay is greater than zero. Otherwise the user will have to click the Split Bill button if they want to bill another plan.
Auto-Prompt Always: The program will always prompt the user to split-bill regardless of what the copay is.
COB Billing Prompt Type is set to Only Linked Plan:
User Will Prompt: If there is a linked plan, then the program will automatically prompt the user to split bill. If there is no linked plan, then the user will have to click the Split Bill button if they want to bill another plan.
Auto-Prompt when Copay > 0.00: If there is a linked plan, the program will automatically prompt the user to split-bill if the copay is greater than zero. Otherwise the user will have to click the Split Bill button if they want to bill another plan.
Auto-Prompt Always: If there is a linked plan, the program will always prompt the user to split-bill regardless of what the copay is.
Linking a Plan
A “linked plan” is when you set a “Secondary Plan” in Patient File (F3) - Insurance Plans.
In this instance, the primary plan would be “CAREMARK” and the linked plan would be “AETNA”. When linking a secondary plan you will have to have the information for Plan 2 in insurance plans to Save Plans, in some instances if you’d like to add the secondary insurances “OP ID Qualifier” and the “OP ID” click on More Options on the secondary insurance to input the information.
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 File and enter the plan from insurance plans screen.
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 (F5) tab, when you click the COB / Dual Billing tab you will see the following options for Coordination of Benefits/Dual Billing Settings.
Auto-Learn COB Settings
If set to “Yes”, the OPPRA fields will be sent to the secondary insurance. BestRx will generate this combination for certain insurances that take both values for OPPRA while this may not apply to some insurances that are being billed, if it’s being rejected simply remove the second line qualifier or turn this setting to “NO” so BestRx doesn’t generate this combination in COB.
Send Other Payer Amount Paid (OPAP - Amount Paid by Insurance) Info & Combinations
If set to "Yes," the OPAP fields will be sent to the secondary insurance. These fields indicate how much the primary insurance paid. If dual billing was set up before sending the claim to the primary insurance, the fields will populate automatically.
Typically, only 07-Drug Benefit needs to be reported (Amount Paid by Insurance), which equals the Cost + Dispensing Fee paid by the primary insurance, excluding the copay. For example, if the primary insurance approved $268.20 but paid $218.00 (with a $50 copay), the OP Amount Paid would be $218.20.
In some cases but rarely, other values such as 10-Sales Tax or 09-Compound Preparation Cost may also need to be reported, depending on what the primary insurance paid. These values will be available on the primary insurance claim response screen.
Anytime OPAP values are sent, the Other Coverage Code on Rx Processing should be set depending on the primary insurance’s payment status.
OCC 02: Approved claim where primary insurance paid something, should also include OPPRA (Patient Pay Amount) (e.g. $50.00)
Example Combination: OPAP 07 - Drug Benefit (218.20) & OPPRA 06 - Patient Pay Amount (50.00)
OCC 03: Rejected claim by primary insurance, should not include OPPRA, should include O.P. Reject Code
Example Combination: OPAP 07 - Drug Benefit (0.00) & OPPRA (Empty) & Reject Code (e.g. 70, A5)
OCC 04: Approved claim but primary insurance did NOT pay anything (e.g. 0.00)
Example Combination: OPAP (0.00) & No OPPRA (Empty), or No OPAP (Empty) & OPPRA (Empty)
Claim Response - O.P. Amount Paid
Send OP Patient Responsibility Amount (OPPRA - Patient Pay Amount) Info & Combinations
If set to "Yes," the OPPRA fields will be sent to the secondary insurance, showing how much the patient owes for the prescription and why. If dual billing was set up before submitting the claim to the primary insurance, these fields will populate automatically.
The values required will appear on the primary insurance response screen. Some insurances require a breakdown of the Patient Pay Amount, others need only the total, and some require both. Details are provided on the following pages.
Anytime OPPRA values are sent, the Other Coverage Code on Rx Processing should be set depending on the primary insurance’s payment status or copay.
Most important combination when focusing on only coupons is OCC 08
OCC 08: Claim is billing for copay.
Example Combination: ONLY OPPRA 06- Patient Pay Amount or 05- Amount of Copay (e.g. 50.00)
Secondary Insurance Combinations
OCC 02: Approved claim where primary insurance paid something, should also include OPPRA (Patient Pay Amount) (e.g. $50.00)
Example Combination: OPAP 07 - Drug Benefit (218.20) & OPPRA - Patient Pay Amount (50.00)
OCC 03: Rejected claim by primary insurance, should not include OPPRA, should include O.P. Reject Code
Example Combination: OPAP 07 - Drug Benefit (0.00) & OPPRA (Empty) & Reject Code (70, A5)
OCC 04: Approved claim but primary insurance did NOT pay anything (e.g. 0.00)
Example Combination: OPAP (0.00) & No OPPRA (Empty), or No OPAP (Empty) & OPPRA (Empty), less commonly there is OPPRA.
Claim Response Screen - O.P. Patient Responsibility Amount
Send OPPRA Component Amounts
The total Patient Pay Amount could consist of many different values.
The total Patient Pay Amount can include various components, with the most common being the 05-Amount of Copay and 01-Amount Applied to Periodic Deductible. Other components, such as 07-Coinsurance or 03-Sales Tax, may also be included. Use the drop-down menu on the COB screen to view all possible values.
If the insurance company requires individual reporting of the Patient Pay Amount's components, you can find these values on the primary insurance's response screen.
If only the total Patient Pay Amount is displayed, it typically indicates that the 05-Amount of Copay is the sole component, which is why it isn't listed separately. However, if other components are involved, they will be detailed along with the total amount on the response screen.
For patients set up for dual billing, these fields will populate automatically before billing the primary insurance.
Send OPPRA Total Amount
When an insurance company requires the Total Patient Pay Amount to be sent in the OPPRA fields, use the 06-Patient Pay Amount value found on the primary insurance response screen. If the patient was set up for dual billing before billing the primary insurance, this field populates automatically.
If sending the component values of the Patient Pay Amount, their sum must match the Total Patient Pay Amount.
For example:
25.00 (01 - Amount Applied to Periodic Deductible)
10.00 (05 – Amount of Copay)
2.00 (13 – Amount Attributed to Processor Fee)
Total: 37.00 (06 – Patient Pay Amount)
If the secondary insurance doesn't require component values, only 06-Patient Pay Amount : 37.00 would be sent
Send Benefit Stage Info (Benefit Stage Amount/Qual)
If the primary insurance is a Medicare Part D or Part B claim, the secondary insurance may require Benefit Stage info, which explains how the primary insurance calculated the approved amount. This can be found on the primary insurance response screen. If the patient was set up for dual billing, these fields will populate automatically.
Benefit Stage info must be sent with OPAP, OPPRA, or both. If both are sent, the sum of the Benefit Stage values should match the sum of the OPAP and OPPRA values (excluding the 06-Patient Pay Amount if both component and total values are sent).
If the primary insurance doesn’t provide Benefit Stage info, it cannot be sent to the secondary insurance. We cannot assume or estimate these values. If needed, we would contact the insurance companies to resolve the issue, though this has not occurred yet.
The Other Coverage Code depends on whether OPAP or OPPRA values are sent with the Benefit Stage info. See the OPAP and OPPRA sections for details.
A screenshot of the COB and Response screens showing the Benefit Stage information is provided below.
COB - Benefit Stage Qualifier/Benefit Stage Amount
Response Screen for claim with Benefit Stage Info
The Benefit Stage Amount Qualifier is based on the Benefit Stage Amount/Qual value in the claim response. Examples include 02 - Initial Benefit, 01 - Deductible, or 03 - Coverage Gap (donut hole). If the claim response includes two qualifiers, you may need to input both or one into the COB stage amount field, depending on the rejection.
Send Payment Info for Rejected Claims
This option applies when a claim is rejected and the secondary insurance requires OPAP info. Some plans require sending a value of 0.00 for 07-Drug Benefit, while others require the field to be left blank. If "Send Payment Info for Rejected Claims" is set to Yes, we will send 0.00; if set to No, no OPAP values will be sent.
For secondary plans that require OPPRA values, we don’t send OPPRA values when the primary insurance rejects the claim since no Patient Pay Amounts are provided.
In all cases of claim rejection, the O.P. Reject Codes should be sent to the secondary insurance to explain the rejection. These codes are found on the primary insurance response screen and will populate automatically if the patient was set up for dual billing.
Claim Response - O.P. Reject Code
Send COB Info on Reversals
When reversing secondary claims, some insurance companies require the OP Coverage Type from the COB segment to confirm it's a secondary claim reversal. Others may reject the reversal if the COB segment is sent, while most don't require it and will ignore it if sent.
For insurance plans that require COB info for secondary reversals, ensure the option is set to Yes. For plans that don’t want it, set it to No.
If COB info is required, always reverse the secondary insurance before the primary. Reversing the primary first deletes the COB info, preventing the secondary reversal.
If the primary is accidentally reversed first, enter temporary COB info for the primary plan (select the primary plan and OP Coverage Type) before reversing the secondary. Then, delete the dummy info to avoid future billing issues
Claim Response Component Examples
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
Other Notes About COB Billing
For OPAP values, do not send 08–Sum of All Reimbursement for D.0 claims. This value was used in NCPDP version 5.1 but has been retired in version D.0. Sending it may lead to claim rejection or incorrect payment. Although it remains in the drop-down for now, it will be removed soon as insurers transition to D.0.
The guidelines for Other Coverage Codes come from NCPDP seminars and tutorials, and most insurance companies follow them. However, some insurers may still require codes that differ from these guidelines.
The Other Coverage Code values 05, 06, and 07 have been eliminated in version D.0 and will soon be removed from the drop-down, but their removal won't cause issues as they were rarely used in version 5.1.
In version D.0, the COB segment is required for all secondary insurance claims. Unlike version 5.1, where certain plans didn’t want the COB segment with Other Coverage Code 08, the new rules mandate it. Hopefully, insurance companies will comply with this change.