This feature is currently in beta and is subject to change.

Some patients have multiple health plans. For example, a dependent may have coverage with two private insurance companies through their parents. When a patient has active coverage with multiple plans, you need to know which health plan is primarily responsible for paying claims (coordination of benefits).

You can use a coordination of benefits (COB) check to determine:

  • If a patient is covered by more than one health plan
  • Whether there is coverage overlap between plans
  • Whether coverage overlap requires coordination of benefits
  • Each payer’s responsibility for payment (primacy) in coordination of benefits scenarios

COB checks can help ensure that you submit claims to the correct payer and avoid claim denials. We recommend performing coordination of benefits checks for all new patients who have coverage through one of Stedi’s supported payers. Visit the Payer Network for a complete list.

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How COB checks work

You submit a coordination of benefits request with information for one of the patient’s health plans. The information you provide is similar to a standard eligibility check, including the patient’s name, date of birth, and health plan information.

Once you submit the request, Stedi searches a national database of eligibility data from state and commercial payers. This database has 245+ million patient coverage records from 45+ health plans, ASOs, TPAs, and others, including participation from the vast majority of national commercial health plans. Data is updated weekly to ensure accuracy.

If the patient has coverage with multiple health plans, Stedi works to determine whether coordination of benefits is required and which payer is the primary payer. The response includes information about the patient’s active health plans, the responsibility sequence number for each payer if available (such as primary or secondary), and whether coordination of benefits is required.

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Check COB

Each COB check must be for a participating health plan for which the patient has coverage. For example, if the patient has coverage from Cigna and UnitedHealthcare, a COB check to Aetna will return an error.

To prevent accidentally sending checks to unsupported payers, Stedi only provides the option to perform a COB check within successful eligibility checks to supported COB payers. Visit the Payer Network for a complete list.

To submit a new COB check:

  1. Go to the Eligibility searches page.
  2. Click the eligibility check for the patient you want to check for coordination of benefits. This must be a successful eligibility check for the patient’s health plan - failed checks can’t be used as the basis for COB checks.
  3. Click View to review the details of the eligibility check.
  4. Click New COB check to open the coordination of benefits check form. Stedi prefills the patient’s information from the eligibility check.

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Accurate patient data

COB checks are significantly more sensitive to data accuracy than eligibility checks. To perform successful COB checks, the patient information you provide in the check must match the payer’s data exactly.

For example, if a payer has a patient’s name stored as “Jonathan Doe”, they may return benefits information when you submit an eligibility check for “Jon Doe”, as long as they can identify the patient through the other information provided. However, a COB request for “Jon Doe” will fail because the name doesn’t match the payer’s records exactly.

To avoid unnecessary COB check failures, we strongly recommend that you first submit an eligibility check request for the patient. Then use the following data from the successful payer benefit response to build the COB request: firstName, lastName, dateOfBirth, memberId.

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Service type code

You can submit COB checks with the 30 service type code for Health Benefit Plan Coverage. This is the broadest service type code that covers all medical services and subtypes included in the patient’s health plan.

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Interpret COB response

The COB response includes information about the patient’s active health plans, subscriber information, and coordination of benefits.

Unlike standard eligibility checks, the COB response shape is standardized across all supported payers. There are no payer-specific variations in what information is included or how the response is structured.

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COB status

The coordinationOfBenefits object contains status information about whether a COB instance exists and whether Stedi was able to determine the primary payer.

"coordinationOfBenefits": {
    "classification": "CobInstanceExistsPrimacyDetermined",
    "instanceExists": true,
    "primacyDetermined": true,
    "coverageOverlap": true,
    "benefitOverlap": true
  },

A COB check response can have one of the following statuses, indicated by the coordinationOfBenefits.classification property.

statusDescription
MemberFoundNoCobThe patient has coverage with the payer you checked, but Stedi didn’t find any other health plans with overlapping coverage. Note that Stedi can only report information for other COB-supported health plans from our payer list. For example, if the individual has coverage from Cigna and Medicare, a COB check to Cigna will state that no COB was detected, since Medicare is not a supported payer. You can find a complete list of supported payers for COB checks in the Payer Network.
CoverageOverlapNoBenefitOverlapThe patient has overlapping coverage with at least one other health plan, but there is no benefit overlap between the plans. Coordination of benefits is not required.
CoverageOverlapExistsNotSubjectToCobThe patient has overlapping coverage with at least one other health plan, but coordination of benefits is not required.
CobInstanceExistsPrimacyUnDeterminedThe patient has overlapping coverage with at least one other health plan and coordination of benefits is required. However, Stedi could not determine the primary payer. We recommend contacting the patient’s health plans for further guidance.
CobInstanceExistsPrimacyDeterminedThe patient has overlapping coverage with at least one other health plan, and Stedi was able to identify the primary payer.

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Payer primacy

The response includes a benefitsInformation object with code = R when Stedi finds overlapping coverage with another health plan.

The benefitsInformation.benefitsRelatedEntities object contains information about the other payer, and the entityIdentifier property indicates the payer’s primacy for payment on claims when this information is available. It can be set to:

  • Payer: Stedi didn’t find a COB instance or could not determine primacy.
  • Primary Payer: This payer is the primary payer for the service type.
  • Secondary Payer: This payer is the secondary payer for the service type.
  • Tertiary Payer: This payer is the tertiary payer for the service type.

In the following example, the patient has overlapping coverage for medical care services with Cigna, the primary payer for medical care services.

{
      "code": "R",
      "name": "Other or Additional Payor",
      "serviceTypeCodes": [
        "1"
      ],
      "serviceTypes": [
        "Medical Care"
      ],
      "benefitsDateInformation": {
        "coordinationOfBenefits": "2024-07-01"
      },
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Primary Payer",
          "entityName": "CIGNA",
          "entityIdentification": "PI",
          "entityIdentificationValue": "1006"
        },
        {
          "entityIdentifier": "Insured or Subscriber",
          "entityFirstname": "JOHN",
          "entityMiddlename": "X",
          "entityIdentification": "MI",
          "entityIdentificationValue": "00000000000",
          "entityLastname": "DOE"
        }
      ],
      "subscriber": {
        "dateOfBirth": "2002-12-31"
      }
    }

When Stedi can’t reliably determine primacy, you should contact the patient’s health plans directly for further guidance.

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Sample response

The following example COB response shows information for a dependent who is covered by multiple health plans through their parents’ policies. The COB check was submitted to Aetna with a service type code of 30 and a date of service of 2024-11-27.

The response indicates the following:

  • Active coverage: The patient has active coverage with Aetna for medical care services, pharmacy services, and vision services. This is indicated by the three objects in the benefitsInformation array with the code set to 1.
  • Coverage overlap: The patient has overlapping coverage for medical care services between two health plans. This is indicated by the benefitsInformation object with the code set to R.
  • Primacy: The other health plan is Cigna, listed in benefitsInformation.benefitsRelatedEntities. Cigna is the primary payer for medical care services.
  • COB instance: There is a COB instance for medical care services on the date of service provided in the request. This is indicated in the coordinationOfBenefits object.

Based on this response, you must send claims first to Cigna as the primary payer for medical care services. Once Cigna adjudicates the claim, you can send another one, if necessary, to Aetna as the secondary payer (subject to specific payer claims processing rules).

Before sending claims we’d also recommend sending a separate eligibility check to Aetna to verify coverage status.

{
  "benefitsInformation": [
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "1"
      ],
      "serviceTypes": [
        "Medical Care"
      ],
      "benefitsDateInformation": {
        "benefitBegin": "2023-03-01"
      },
      "subscriber": {
        "dateOfBirth": "2002-02-27"
      }
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "88"
      ],
      "serviceTypes": [
        "Pharmacy"
      ],
      "benefitsDateInformation": {
        "benefitBegin": "2023-03-01"
      },
      "subscriber": {
        "dateOfBirth": "2002-02-27"
      }
    },
    {
      "code": "1",
      "name": "Active Coverage",
      "serviceTypeCodes": [
        "AL"
      ],
      "serviceTypes": [
        "Vision (Optometry)"
      ],
      "benefitsDateInformation": {
        "benefitBegin": "2023-03-01"
      },
      "subscriber": {
        "dateOfBirth": "2002-02-27"
      }
    },
    {
      "code": "R",
      "name": "Other or Additional Payor",
      "serviceTypeCodes": [
        "1"
      ],
      "serviceTypes": [
        "Medical Care"
      ],
      "benefitsDateInformation": {
        "coordinationOfBenefits": "2024-07-01"
      },
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Primary Payer",
          "entityName": "CIGNA",
          "entityIdentification": "PI",
          "entityIdentificationValue": "1006"
        },
        {
          "entityIdentifier": "Insured or Subscriber",
          "entityFirstname": "JOHN",
          "entityMiddlename": "X",
          "entityIdentification": "MI",
          "entityIdentificationValue": "00000000000",
          "entityLastname": "DOE"
        }
      ],
      "subscriber": {
        "dateOfBirth": "2002-12-31"
      }
    }
  ],
  "coordinationOfBenefits": {
    "classification": "CobInstanceExistsPrimacyDetermined",
    "instanceExists": true,
    "primacyDetermined": true,
    "coverageOverlap": true,
    "benefitOverlap": true
  },
  "dependent": {
    "firstName": "JORDAN",
    "lastName": "DOE",
    "gender": "M",
    "dateOfBirth": "2002-12-31",
    "relationToSubscriber": "Child",
    "relationToSubscriberCode": "19",
    "address": {
      "address1": "1 MAIN ST.",
      "city": "NEW YORK",
      "state": "NY",
      "postalCode": "10000"
    }
  },
  "errors": [],
  "meta": {
    "applicationMode": "production",
    "traceId": "01JDQFT4W3KTWZNTADEZ55BFFX",
    "outboundTraceId": "01JDQFT4W3KTWZNTADEZ55BFFX"
  },
  "payer": {
    "name": "Aetna",
    "payerIdentification": "AETNA-USH"
  },
  "provider": {
    "providerName": "AETNA-USH",
    "entityType": "Non-Person Entity",
    "npi": "1999999984"
  },
  "subscriber": {
    "memberId": "W000000000",
    "firstName": "JOHN",
    "lastName": "DOE",
    "address": {
      "address1": "1 MAIN ST.",
      "city": "NEW YORK",
      "state": "NY",
      "postalCode": "10000"
    }
  }
}

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Follow-up eligibility checks

Our COB data is updated weekly, and the response doesn’t contain complete details about the patient’s coverage with each health plan.

When Stedi finds overlapping coverage, we strongly recommend conducting follow-up eligibility checks with each payer to verify coverage status and retrieve the patient’s complete, up-to-date benefits information.

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