COB PROCESSING FOR CAPITATED SERVICES Sample Clauses

COB PROCESSING FOR CAPITATED SERVICES. Requirements: - When a provider is capitated for a service (or groups of services) some health plans do not expect the provider to receive additional reimbursement from COB for those services. - In the event that a provider submits a claim that contains both capitated and FFS services along with a COB, the COB should only be applied to the FFS lines. 22 Overview: - A new rule will be added that will identify whether services that are capitated are to be included in COB calculations. - QCS_EDIT_COBCAP - COB Calculations apply to capitated services. - This will be an enable/disable edit. - If the rule is set to ENABLE, then any COB adjustments to be made to claim lines should ONLY be made to lines that are to be paid FFS. Lines flagged as capitated should not have any COB applied to them. (Claims containing capitated only services should not suspend for reason 216). - For example, assume that Standard COB Rule is in effect. A three line claim is submitted with a COB of $100. Line 2 is for a capitated service. Line 1 has a contracted amount of $100.00, line 2 has a contracted amount of $50, and line three has a contract amount of $50. If the COBCAP rule is enabled, the claim will have $67 allocated to line 1 and $33 allocated to line 3. If COBCAP is disabled, $50 is allocated to line 1, $25 is allocated to line 2 and $25 is allocated to line 3. Development Timeline: 90 days
Sample 1
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Related to COB PROCESSING FOR CAPITATED SERVICES

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