Are Your Systems Ready to Properly Process the CMS Annual Coordination of Benefits-Other Health Insurance (COB-OHI) Files?

The CMS Annual COB-OHI process is quickly approaching, and health plans must be prepared to complete mandatory processes to remain compliant.

The Centers for Medicare and Medicaid Services (CMS) play a crucial role in ensuring efficient coordination of benefits for individuals with Medicare coverage. The CMS COB-OHI File is an essential resource that facilitates seamless claims processing and maximizes healthcare coverage.Compliance Consulting

What is the CMS COB-OHI File and Why is it Critical to My Health Plan?

The Annual CMS COB-OHI File is a full-replacement file maintained by the Centers for Medicare and Medicaid Services. It contains information about individuals with Medicare coverage who also have other sources of healthcare insurance, such as employer group health plans, private insurance, Medicaid, or third-party liability insurance. Inaccurate data sets can lead to a multitude of risks for a health plan including incorrect copay amounts charged during point-of-sale pharmacy purchases and costly Complaint Tracking Module (CTM) issues.

Make Sure Your Health Plan is Compliant!

Annually, CMS requires each Part D plan to reach out to their beneficiaries for whom Other Health Insurance (OHI) was received to confirm COB information. Plans may use information on the annual full-replacement file to trigger the annual mailing. The letters should be done; 1) early enough in the year to maximize use of the information obtained and 2) well in advance of open enrollment to minimize member confusion.

Why Choose CODY’s Membership Suite Reconciliation System?

CODY’s Membership Suite Reconciliation System bridges the gap between CMS’ requirements and health plans’ processing of the Annual COB-OHI File.

CodySoft Recon™ is modular, queue-based, business-rules driven, and continually updated to reflect governance changes and best practices. Key benefits to the COB Module:

The COB Module

  • Ingests your plan membership and CMS-generated files.
  • Systematically creates workable transactions and queues for each record to be dispositioned, tracked and audit ready.
  • Houses advanced, tested logic that identifies all records where an Annual COB letter is required by carving out:
    • Invalid Records (daily and annual)
    • Duplicate Records (daily and annual)
    • Third Party Liability Records
    • Inactive Records
  • Auto-generates CMS required correspondence.
  • Supports the CMS One-Third Financial Audit

Reminders from our experts: Don’t load the files without having a plan in place!

  • The intended purpose of the file is to review your COB information in comparison to the once-a-year cumulative COB file. Don’t override updated information that has been submitted and not processed by ECRS.
  • Evaluate all primary (PRM) coverage records and understand any impact to your members of applying un-validated information to pharmacy claims payment.

Don’t do this alone! Without the support of a software tool, consuming and processing CMS’ Annual COB File is a complex, labor-intensive process.

We’re Here to Help

To learn how CODY® can support the Annual COB-OHI file process this season and the overall OHI process throughout the year, contact us today to find out more or request a demo.

About us: Founded in 2006, CODY® is an Industry leader in Governance, Risk, and Compliance (GRC) Solutions designed exclusively for health plans. We enable over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico to mitigate compliance risk, maximize efficiencies, and improve outcomes. Our Enterprise technology and innovative solutions reduce administrative costs, increase accuracy, ensure regulatory compliance, and provide a better experience for plan members and providers.