HealthCare News

Coordination of Benefits and Accident Inquiry Process

Issue: #405 DEC2018

Topic: Education


As Blue Cross Blue Shield of North Dakota (BCBSND) transitions to the new system, some new efficiencies are being gained with previous claims processes. One of those is the process of obtaining information related to injuries or accidents. This information is requested of members in order to determine coverage. On the new claims processing system BCBSND has gained processing automation related to letters that are sent asking for this information. The claims system will auto-generate member-specific letters based on diagnosis code. The letters each contain a unique barcode that ties the letter to the member’s individual case so when the letter is returned by the member, the system will be automatically updated. With this new automation BCBSND will be discontinuing the use of the online form, titled “Workers Compensation/No Fault/Subrogation”, that was previously available. Effective January 1, 2019 the form that was available on the BCBSND website will no longer be accepted.

To help providers prepare for this change, BCBSND would like to provide a general overview of the Coordination of Benefits and Accident process.

Coordination of Benefits: For these claims, BCBSND follows a “pay and pursue” process. This means the claim will be paid and then BCBSND will pursue any alternate insurer. BCBSND works proactively with members throughout the year to try and gather other payer information. The form will continue to be available on the BCBSND website for members to update and return with their other insurance carrier information.

Accident (Worker’s Compensation): For these claims, BCBSND follows a “pursue and pay” process. This means BCBSND will first do its due diligence in determining if the claim is related to an on-the-job accident and then pay the claim. For accident claims, the claims system auto-generates a member-specific letter when such a claim is received. The claim is suspended for 10 business days, waiting for the member to return the requested information. If no response is received during that time, the claim will be systematically rejected as member liable, indicating BCBSND is waiting for information from the member.

BCBSND has received questions from providers that want to proactively work with the member on accident claims. BCBSND would encourage providers to inform members that present with an accident-related injury that they may receive a form from their insurer and they should complete and return that form to BCBSND as soon as possible.