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Coordination Of Benefits

Proactive. Accurate. Efficient.
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PROBLEM STATEMENT

Overview

Health plans face significant operational and financial challenges due to the Coordination of Benefits (COB) process. As many as 15% of health plan members have other insurance coverage, creating a multi-million dollar impact on time, resources, and the bottom line. On average, health plans spend approximately 12% of their premiums managing COB, as it can take up to five times longer to settle a COB claim compared to a standard claim. More than 50% of COB issues go unidentified, leading to financial leakage and costing payers millions in wasted pay-and-chase efforts. The current COB process is largely a manual, vendor-driven, and postpay recovery-focused “black box” model, capturing only 30-40% of potential savings opportunities.
Our COB Solution addresses these challenges by leveraging AI for COB determination and claims reviews, significantly reducing manual work, cutting down on errors, and accelerating decision times. This results in reduced COB costs, fewer claim overpayments, and improved recovery rates for health plans.
BENEFITS

The Difference AI Can Make

Revolutionizing Provider Data Management

> 50%

Increase in COB Identification

> 98%

COB Determination Accuracy 

80%

Reduction in COB Claim Processing Time 

> 20%

Reduction in Revenue Leakage

>30%

Increase in New Recovery Leads

>80%

Touchless Prior Auth Resolutions

30%

Reduction in Resubmissions
HOW IT WORKS

Inside COB

SOLUTION OVERVIEW

Simplify Prospective and Retrospective COB Validation with AI  

COB Identification

Our solution proactively identifies potential COB scenarios by continuously monitoring and analyzing member record updates, both from internal sources (like new enrollments or member updates) and external data providers (such as CAQH).

COB Determination

The system identifies complex COB cases by analyzing member attributes and Qualifying Life Events that correlate with complex coverages and incorrect COB determinations. It accurately determines primary and secondary payer by contextually applying order-of-benefits rules and providing clear reason codes.

COB Updation

Our system identifies required actions and provides options to assign COB cases to COB operators. For each assigned case, operators can view membership details—including coverage and payer COB information—and approve COB updation in Member record.

COB Validation

The system validates COB data for incoming claims, flagging those with incorrect COB information for further review. Whenever COB information is updated, the system automatically conducts retrospective claim reviews to identify overpayments and quantify potential recovery opportunities..
APPLICATION

Drive Prior Auth & UM Efficiency with Flexible AI

SOLUTIONS

Coordination of benefits (COB)

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Claims AI

Improve auto adjudication rates and claims quality with real-time intelligent claim edits. Predict and orchestrate potential claim suspensions to reduce and resolve any manual intervention.

Intelligent Contract Management

Leverage Generative AI and LLMs to extract, comprehend and integrate contract information for downstream Payer operations. Improve data quality, compliance and contract configuration throughput…

Enable Proactive, Accurate, and
Efficient COB Validation

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