Order of COB Processing
The order is set by which plan is the primary payer (pays first), secondary payer (pays the remaining balance, if any, after the primary processes), and, less commonly, tertiary payer (a third plan). The order follows guidelines based on the type of insurance and each plan's rules. The secondary payer may cover costs the primary didn't, depending on COB rules.
COB Order Guidelines
Employer-Sponsored Insurance vs. Other Insurance:
If a person is covered under an employer group health plan (through their own job or a spouse’s job), that insurance is generally considered the primary payer.
If the patient has additional coverage, such as a spouse’s employer-sponsored plan or an individual health insurance policy, the other insurance may be the secondary payer.
Group health plan coverage is the primary payer over a Marketplace coverage option.
Medicare Coordination of Benefits:
Medicare is usually the secondary payer when a person has other primary insurance. However, there are exceptions to that rule. Medicare is the primary payer in the following situations:
The subscriber is retired and the group health plan has less than 20 employees (check the Tax Info on the settings tab to view employee count)
The subscriber is aged 65 or older and has Medicare but no other group health plan coverage.
Note: If the individual is under age 65 and has disability coverage (e.g., the individual is enrolled in Medicare Part A and B because of disability), Medicare will be the secondary payer if the individual has other employer-based group health coverage.
Medicaid Coordination:
Medicaid is always the payer of last resort, meaning it typically pays after all other insurance options have been exhausted.
TRICARE and Veterans’ Benefits:
If a person is covered by TRICARE (military insurance) and has other health insurance, TRICARE will usually be the secondary payer. However, TRICARE may become the primary payer if the patient is actively deployed. Federal law prohibits other insurance from being primary over TRICARE for active duty members.
For active duty members, no COB applies: TRICARE pays first and in full for all covered services (for the member only, not for the full family). Other health insurance cannot be billed for services related to active duty treatment.
Veterans Affairs (VA) benefits are considered a secondary payer unless the treatment is specifically related to a service-connected condition, in which case the VA may become the primary payer.
Marketplace Exchange Coverage:
If someone has access to a group health plan (for example, through their employer or a spouse’s employer), that plan is considered the primary payer.
Marketplace coverage is individual coverage. It is not designed to coordinate benefits with group health insurance.
If a member chooses to also purchase a Marketplace plan, the Marketplace plan would generally pay secondary, but in practice it usually won’t coordinate at all — instead, it will just pay benefits as if it were the only coverage.
No-Fault, Workers' Compensation, and Auto Insurance:
In cases where the injury is due to a work-related incident or auto accident, workers' compensation or auto insurance is generally considered primary.
Health insurance would then pay as the secondary payer once these claims have been processed.
Additional COB Rules
Plan without a COB provision: If a plan has no COB provision, it is primary.
Active vs. retired/laid-off: The plan covering someone as an active employee is primary over the plan covering them as retired or laid-off.
Dependent child: The plan covering the custodial parent is primary, followed by the plan covering the custodial parent's spouse, then the non-custodial parent, and finally the non-custodial parent's spouse.
Birthday Rule: For a child covered by both parents, primary responsibility falls on the parent whose birthday is earlier in the calendar year; the later birthday is secondary. Order is determined by month; if the same month, then by day.
Longer coverage: If both parents have the same birthday, the plan that has covered the parent longer is primary.
Court Decree Exception: If a court decree assigns responsibility for a child's health coverage to one specific parent, that parent's plan is primary — this overrides the custody and birthday rules. The custody order applies only when there is no such decree, or when the decree assigns joint responsibility without naming one parent.
Examples of COB Order in Practice
Example 1: Employee and Spouse with Employer Insurance
Primary Payer: The individual’s own employer-sponsored health insurance.
Secondary Payer: The spouse’s employer-sponsored health insurance.
Example 2: Medicare and Employer Insurance
Primary Payer: Employer group health plan (if the individual is employed or the spouse has employer insurance).
Secondary Payer: Medicare (for someone who is eligible for Medicare and is covered by an employer plan).
Example 3: Medicare and Medicaid
Primary Payer: Medicare (if the individual is eligible for both).
Secondary Payer: Medicaid (after Medicare has processed the claim).
Example 4: Auto Insurance and Health Insurance
Primary Payer: Auto insurance (if the injury is related to an automobile accident).
Secondary Payer: Health insurance (if there is additional coverage).
COB collection
COB status from claims
When an incoming claim lists another payer, Yuzu saves a COB record from it automatically. However, a third of these have no payer order so additional follow is still necessary,
COB status from completed forms
Yuzu sends a Coordination of Benefits form after one of three events: a new enrollment, the member turning 65, or staff sending it again. One member gets the form, but it asks about other coverage for each family member. Yuzu decides the payer order separately for each person.
The COB status can be seen on the member’s “COB” tab on their profile.
An open COB form gets a reminder every 7 days, up to 4 reminders. After that it goes to manual follow-up.
Relative to other forms, COB forms have a low completion rate. This impacts our ability to adjudicate claims. If the member has no other coverage, the member should still complete the form and say so.
Plan designers and the sponsor (HR) can fill in and submit the COB form for the member if neessary. Brokers can view it but can't submit it.
What happens to pended claims after the COB form is returned
The other coverage the member reports is saved to the COB tab. Yuzu sets itself as primary automatically for subscribers who are not retired. For dependents and retirees, staff must confirm the payer order. Held claims are re-checked every Thursday and continue processing once Yuzu is confirmed as primary. Claims already denied for COB (remark code COB3) are not reprocessed automatically. The claims team finds and reprocesses them using the COB Reprocessing report. The payer order must be confirmed again every 365 days.
Impact to claims on an outstanding COB
If the other coverage is on file and it pays first, the claim goes to manual review. The examiner needs the primary plan's EOB and pays only the remaining balance. If other coverage is on file but the payer order is unknown, then the claim goes to manual review until someone confirms the order. If the claim says another payer is primary, the claim goes to manual review, unless a form or staff record confirms that Yuzu is primary.
Primary EOB required when Yuzu is secondary
When another plan is primary, Yuzu cannot process the claim until the primary plan has processed it. The provider or member must send the primary plan's EOB to claims@yuzu.health with the claim number.
The examiner uses the EOB to determine the remaining payable amount under the plan's benefits. If the EOB is not received, the claim may be denied with remark code COB3. Once the EOB is submitted, the claim can be reprocessed.
Releasing a COB hold
A claim can be released when the other coverage does not apply to the date of service. Staff can resolve this on the member's COB tab:
Other coverage ended before the date of service: Add the end date to the COB record. Records whose coverage ended before the claim dates are ignored.
Yuzu is primary under COB rules: Set the payer order to show Yuzu as primary, such as when the member is the subscriber or the other coverage is Medicaid.
Incorrect other coverage: If a claim lists coverage the member confirms they do not have, delete the incorrect record.
Clicking "Mark as reviewed" only updates the review date and does not release a held claim. Once the COB information is updated, the claim is re-checked the following Thursday, or an examiner can process it immediately.