Understanding the intricacies of healthcare coverage is a fundamental necessity for individuals navigating the complexities of insurance benefits, which brings into focus the critical role of the Medpartners Coordination of Benefits (COB) questionnaire. Located in Fort Wayne, Indiana, this essential form serves a pivotal function in streamlining the process whereby MedPartners Administrative Services ascertain whether Medicare or other health insurance plans could impact the Coverage of Benefits. Crafted to mitigate delays in claim payments, this form highlights the sheer importance of furnishing accurate information about any concurrent health insurance coverage. Encompassing a wide range of scenarios—from annual updates, new enrollees, additions or termination of other insurances, to adjustments necessitated by changes in dependent or spousal statuses—it is a comprehensive tool designed to clarify coverage intricacies. Further attention is given to special circumstances, such as dependent children in the wake of divorce or separation, underscoring the need for detailed information regarding custodial and health care coverage responsibilities. Additionally, the form's explicit request for details on Medicare coverage for oneself or a spouse underscores the broader scope of insurance interaction and the necessity for detailed reporting in the quest for optimized benefits coordination. As recipients navigate through sections dedicated to other health coverage, special situations for dependent children, and Medicare coverage, the mandatory completion and subsequent submission of this form emerges as a cornerstone practice for ensuring the accurateness of benefits coordination and the prevention of unnecessary delays in claim processing.
| Question | Answer |
|---|---|
| Form Name | Medpartners Cob Online Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | cob online form sample, cob online form template, of form cob questionnaire, form med partners online |
P.O. Box 2602
Fort Wayne, IN 46801
COORDINATION OF BENEFITS QUESTIONNAIRE
This form MUST be completed to notify MedPartners Administrative Services of Medicare or other health insurance coverage for Coordination of Benefits (COB). FAILURE TO COMPLETE THIS FORM WILL RESULT IN DELAYS
TO CLAIM PAYMENTS.
PLEASE CHECK REASON FOR SUBMISSION:
Annual COB update New enrollee Add other insurance Termination of other insurance
Add dependent/spouse
Group Policy # ________________ |
Group or Employer Name |
__________________________________________ |
Member ID # __________________ |
Member/Employee Name |
__________________________________________ |
Address ______________________________________________________ Phone # ________________________
ARE YOU OR ANY OF YOUR COVERED DEPENDENTS ALSO COVERED BY ANOTHER GROUP HEALTH PLAN?
NO – Please skip the rest of the questions, sign at the bottom, and return.
YES – Complete entire form, sign, and return.
SECTION 1 OTHER HEALTH COVERAGE INFORMATION (Excluding Medicare – See Section 3)
Please provide information about policy holder of the other health coverage. Attach additional pages if needed.
Name of policy holder of other coverage |
Relationship to you |
|
Social Security # |
|
Employer |
|
|
|
Birth date |
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Insurance company name |
|
Insurance company address |
|
|
|
|
|
|
Phone # |
||||||
|
|
|
|
|
|
|
|
|
|
|
|
||||
Member ID/Policy # |
|
Group # |
|
|
|
|
Effective date |
|
Cancellation date |
||||||
|
|
|
|
|
|
|
|
|
|
||||||
Type of coverage: Single |
Family |
|
Type of Plan: |
Medical |
Dental |
Vision |
Prescription Drug |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|||||
Who is covered by this other plan? Include yourself if applicable. |
|
|
|
|
|
|
|
|
|
||||||
|
Name (First and Last) |
|
|
|
Relationship to You |
Effective Date |
Cancellation Date |
||||||||
1. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
2. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
3. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
4. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
5. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
6. |
______________________________________________________ |
_____________________ |
________________ |
________________ |
|||||||||||
NOTE: For dependent children of divorced, separated, or
COB FORM 11_19_08
SECTION 2 SPECIAL SITUATIONS FOR DEPENDENT CHILDREN
Fill out this section only if any of your children have health care coverage in addition to the above because of divorce, separation, etc.
Is there a court order that determines responsibility for health care coverage or custody?
No Yes – Attach copy of applicable section pertaining to custody and/or health care coverage.
Who does the court order indicate is responsible for insurance/health coverage? ______________________________________________________
Person responsible for child’s health care coverage |
Social Security # |
Relationship |
Employer |
|
|
Birth date |
|
|
|
|
|
|
|
|
|
Insurance company name |
Insurance company address |
|
|
Phone # |
|||
|
|
|
|
|
|
||
Member ID/Policy # |
Group # |
|
Effective date |
Cancellation date |
|||
|
|
|
|
|
|
|
|
Which children are covered by this insurance? |
|
|
|
||
|
Child’s Name (First and Last) |
Who has custody? |
|
Child’s Name (First and Last) |
Who has custody? |
1. |
___________________________ |
___________________________ |
4. |
____________________________ |
__________________________ |
2. |
___________________________ |
___________________________ |
5. |
____________________________ |
__________________________ |
3.___________________________ ___________________________ 6. ____________________________ __________________________
SECTION 3 MEDICARE COVERAGE
If you or your spouse has Medicare coverage, please complete the following:
Are you covered by Medicare? No |
Yes |
Actively Employed |
Retired |
|||
Reason for coverage: |
Over 65 |
Disabled |
ESRD (End Stage Renal Disease) |
|||
Hospital Part A: Effective Date _______________________ |
|
|
||||
Hospital Part B: Effective Date _______________________ |
|
|
||||
Is your spouse covered by Medicare? |
No |
Yes |
Actively Employed |
Retired |
||
Reason for coverage: |
Over 65 |
Disabled |
ESRD (End Stage Renal Disease) |
|||
Hospital Part A: Effective Date _______________________ |
|
|
||||
Hospital Part B: Effective Date _______________________ |
|
|
||||
MEMBER’S SIGNATURE ____________________________________________ |
DATE ________________________ |
|
Return completed form to: MedPartners Administrative Services |
OR |
Fax to: (260) |
P.O. Box 2602 |
|
|
Fort Wayne, IN 46801 |
|
|
COB FORM 11_19_08