Coordination of Benefits ( COB )
Coordination of benefits (COB) are the rules for how insurance pays when a patient has coverage under more than one plan. You can set up defaults in Family Module Preferences. There are many different ways to calculate COB, made even more complicated by various State laws. Non-duplication rules can vary, depending on the carrier.
On the Secondary Insurance plan, in the Edit Insurance Plan window, Other Ins tab, select a Coordination of Benefits rule.
Open Dental has the following different COB Rule options.
Basic: Secondary pays the lesser of:
For example, on a $100 procedure, primary might pay $80 (80% of its allowed fee).
Standard: Secondary pays the lesser of:
For example, on a $100 procedure, primary might pay $80 (80% of its allowed fee).
Carve Out: (Non-Duplication) Secondary reduces what they will pay by what primary paid.
Calculation used: Secondary InsEst = (Secondary Allowed - Secondary Deductible) * Secondary Percentage - PaidOther
Example with deductible: On a $1500 procedure, primary might pay $750 (50% of its allowed fee).
Example without deductible (Non-Duplication: On a $100 procedure, primary might pay $80 (80% of its allowed fee).
Secondary Medicaid: Secondary reduces what they pay by what primary pays. The estimated patient portion becomes a write-off for the secondary insurance. Only use this rule if allowed to bill Medicaid as secondary.
Calculation used: ProcFee - Pri Ins Pay Est (or Ins Pay) - Pri WO - Sec Ins Est
Examples: On a $100 procedure, primary insurance might allow $70, pay $35, and write off $30. Secondary insurance might allow $20, pay $0, and write off $35. The patient will pay $0.
On a $100 procedure, primary insurance might allow $40, pay $20 and write off $60. Secondary insurance might allow $30, pay $10 and write off $10. The patient will pay $0.