Coordination of Benefits vs. Explanation of Benefits

If you’re enrolled in a group benefits plan it’s likely you’ll come across the terms Coordination of Benefits (COB) and Explanation of Benefits (EOB). Each of these terms has to do with submitting claims and receiving reimbursement, so it’s important that you are familiar with them!

In this blog, we’ll outline the details of COBs and EOBs and describe the connection between them, so you’ll be able to submit claims easier and without confusion. 

What is a Coordination of Benefits?

An Employee Benefits plan is centered around receiving health services, as well as paying and adjudicating claims. When you use a service that is part of your health plan (massage, chiropractic, etc), you’ll need to submit a claim to be reimbursed for the amount that you are covered for. Once submitted, your insurance company is responsible for paying your claim and providing you with a record of that payment. In some cases, if your spouse is also part of a group benefit plan, you may be eligible for additional coverage under their plan as well. This comes in handy if your benefits plan only covers a percentage of a service (ex. If only 80% of your massage therapy is covered under your health plan, you may be able to submit the remaining 20% under your spouse’s plan). Figuring out how to coordinate between both plans is where Coordination of Benefits comes in.

Coordination of Benefits (COB) describes the process of claims payment for employees that have dependents who are a part of their own group benefit plan. A dependent is a person who relies on you financially that you include in your group benefits plan, or you are included in theirs. The rules of COBs outline which plan pays first and how benefits are calculated when claims are made to more than one group plan. This is common especially among families with two working adults that each have group benefits that are using their insurance for their child dependents. 

The company that provides your insurance will likely take care of the nitty-gritty details in terms of payment, but there are some things that you should know regarding common issues that happen with a COB. Here are some general rules when it comes to COBs.

1. If you are a member under a plan, you must submit the claim to your own plan first. However, if you have the same status under more than one plan, the plan that covered you the longest pays first. For example, if you have two part-time jobs with benefits, one that started in 2018 and one that started in 2019, you would submit your claim to the plan that was started in 2018 and it will also be the one that pays first.

2. If you and your dependent spouse both have employee benefits and you want to use those benefits on a child, the primary payer (the first payer responsible for claim processing) is decided by the birthday rule. Whoever’s birthday is earlier by month and day in the calendar year is the plan who pays first. If both parent’s birthdays happen to be on the same day, the parent whose first name appears first in the alphabet pays first. For example, if two parents whose child is covered under both insurance have birthdays on October 11 and September 21, the parent with the September birthday will pay the claim first. 

Of course, there are other cases such as for retired people or post-secondary students. For those cases, refer to your employee booklet or contact your plan administrator for more information, so you know how to submit your claims properly. 

What happens if I make a mistake? Well, if you accidentally submit a claim to the wrong insurance provider, it will likely get denied. However, the easy fix to this is to just resubmit it to the right provider. 

It’s important to always keep your dependent information up to date, so when you submit claims, they are processed correctly and won’t get denied. Any time your dependent information is changed, including the birth of a child, or divorce, you should contact your plan administrator with the updates. 

What is an Explanation of Benefits?

An explanation of benefits (EOB) is a statement that includes details about a medical insurance claim that explains what portion was paid to the health provider and how much the employee is responsible to pay. This is generated and sent once it has been fully adjudicated or processed. EOBs will be received any time an employee makes a claim to an extended health care service. The key thing to keep in mind about EOBs is that they are not bills, they are only for your reference to how much you will owe. 

Since EOBs are more of a record of payment rather than a bill, you don’t have to do much with an EOB. You may receive an actual bill later on if you owe money for your claim, but typically you can file away your EOB for reference. EOBs help you understand the value that you get out of our insurance plan. Simply Benefits stores all of your previous EOBs on your employee profile so you can reference them whenever you need to. 

How are they Connected?

EOBs and COBs go hand in hand. The EOB that you receive after you submit a claim can and will be used to receive a COB from another insurance provider.

Here is an example. With Simply Benefits, when you submit any kind of claim, you’ll receive an EOB. If your plan doesn’t cover the full amount, and you want your dependent’s plan to cover the rest, you’ll send the EOB along with the original receipt to your dependent’s health insurer. They’ll take care of the rest of the payment, and you may or may not receive another EOB from the other health insurer. It’s an easy process, but it definitely pays to know the difference between the two terms. 

Final Thoughts

Hopefully, you now have a better understanding of how EOBs and COBs work, so the next time you submit a claim you won’t have to worry about there being any complications.  

If you’re a Simply Benefits plan member, talk to your plan administrator or contact support@simplybenefits.ca to find out details about your coordination of benefits and what to expect from an EOB. 

clear

Subscribe

Stay in the loop!

We won't spam you, promise!

Form title

Simply Benefits Inc. (“us”, “we”, or “Simply Benefits”) is committed to privacy and the protection of your information. By using Simply Benefits’s website, mobile and other applications, and related Services made available through the Apple App Store, the Google PLAY Store, or otherwise on the Internet (together, the “Simply Benefits Applications” or “Applications”), you acknowledge that you accept the practices and policies outlined in this Privacy Policy (“Privacy Policy“). Unless otherwise defined herein, capitalized terms shall have the meanings assigned to such terms set forth in the Terms of Service and which incorporate this Privacy Policy by reference.

At Simply Benefits Corp ("Simply Benefits") we are concerned with safeguarding and protecting the privacy of your personal information.

In accordance with Canada's *Personal Information Protection & Electronic Documents Act* ("PIPEDA") we have established policies on how we collect, use and protect any information that you give us when you use our website or services.

What We Collect

Required Regulatory Information

Simply Benefits collects information needed to provide services and meet the regulatory requirements of our industry. When you open an account or sign up for services, we collect personal information which may include but is not limited to the following:

  • Your name and date of birth

  • Contact details

  • Nature of your employment or business

  • Details about your dependents

  • Demographics

  • Other information relevant to the services we provide

Passive Data Collection

We may receive passively-collected information through a variety of methods, including “cookies” to collect information.

What is a cookie?

Cookies are text files containing small amounts of information which are downloaded to your device when you visit a website. Cookies are then sent back to the originating website on each subsequent visit, or to another website that recognizes that cookie. You can get more information about cookies here.

Simply Benefits uses cookies to track and measure site performance and gather analytics on usage. This information is anonymous and is only used by Simply Benefits to measure and improve our site.

When sending e-mail we may use tracking pixels and urls to help us measure open rates for e-mails and link clicks. This tracking information is used internally only to help us provide relevant content and is never shared with any third parties.

Opting Out of Cookies

If you choose, you may set your browser to notify you when you receive a cookie, giving you the chance to decide whether or not to accept it.

Analytics And Marketing

We use analytics tools and other third party technologies, such as Google Analytics, to collect non-personal information in the form of various usage and user metrics when you use our online Sites and/or Services.

We also use online advertising to reach new potential clients and remarketing tools that allow us to target ads to specific groups of people who have previously interacted with WealthBar’s websites.

Google allows individuals to opt out of it’s advertising cookies from its ad settings page.

Google has additional information available about their Remarketing Privacy Guidelines, and Restrictions.

Where do we store it

Simply Benefits may use third parties to store and process data. Simply Benefits will ensure that such third party service providers have significant expertise with data and digital privacy. Simply Benefits will ensure that personal data is stored and transmitted in encrypted format using technology such as SSL. Third party data storage and processing providers may be located in the United States and as a result personal information may be subject to U.S. privacy law which may differ from Canadian privacy law.

How We Use It

The information we collect is used so we can communicate with you, provide benefits and insurance management services, improve our products and services, and meet our regulatory obligations.

We share only the information which is reasonably required in the normal course of business with third parties such as our custodians, securities regulators, auditors, legal counsel, or law enforcement agencies, to enable them to fulfill their obligations to Simply Benefits and our clients. We may also disclose your personal information to third-party service providers, affiliates and agents in order to assist us in providing the services you requested and to fulfil the purposes for which your personal information has been collected. Outside of this we shall not sell, distribute or lease your personal information to third parties unless we have your permission or are required by law to do so.

How We Protect It

We are committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure, we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect online. In the event that we share your personal information with third-party service providers, affiliates and agents, these parties will be required to adhere to strict confidentiality obligations and practices.

If you have a question, concern or complaint about our privacy policy, please send your comments and your contact details to our Privacy Officer in writing to the following address:

Simply Benefits Corp.

601-460 Doyle Ave,

Kelowna BC

V1Y 0C2

product@simplybenefits.ca

If you believe that any information we have on file for you is incorrect or incomplete, please write to or email us as soon as possible, at the above address. We will promptly correct any information found to be incorrect.