Q. What is Coordination of Benefits?
A. COB is the processing of a claim for a member who has either multiple HMSA drug benefits within a different BIN and PCN (such as an HMSA private business plan plus HMSA Medicare Part D plan) or multiple third-party drug benefits (such as an HMSA plan plus a plan with another carrier).
Q. When can a pharmacy process a COB claim at point-of-sale (POS)?
A. A pharmacy may submit a COB claim at POS for most situations, except a COB claim for an HMSA plan plus a QUEST plan. Dual coverage claims when QUEST is involved should not be processed at POS. A universal claim form (UCF) should continue to be used in these situations.
Q. When is a pharmacy required to process a COB claim at POS?
A. Pharmacies are required by the Centers for Medicare & Medicaid Services (CMS) to process claims at POS if one of the drug benefit plans is a Medicare Part D plan. If a member can be identified as having either a carve-out plan (coverage code 415 or 460) or if a member has an HMSA Medicare Part D benefit with a private business drug rider, a COB claim must be submitted at POS to meet CMS requirements.
Q. Is an update to the pharmacy’s software system required to transmit a COB claim?
A. Yes. Submitting a COB claim requires an update to the pharmacy’s software. Processing a COB claim requires a pharmacy to submit two (or more) separate claims transmissions via HMSA’s claims processor to coordinate plan benefits due to different BINs and PCNs. The current BINs and PCNs listed on the table below should be used to update pharmacy software.
| Line of Business | BIN | Group Number | PCN |
|---|---|---|---|
| Commercial | 004336 | RX3977, RX3979, RX3988, RX3989, RX3990, RX3991, RX3992, RX3993, RX3994, RX3995, RX3996, RX3997, RX3998, RX4473, RX44AA, RX44AB | ADV |
| 012114 | RX24AP | COBSEGADV | |
| QUEST | 004336 | RX3987 | ADV |
| 012114 | RX3987 | COBADV COBSEGADV | |
| 013089 | RX3987 | COMSEGADV COMADV COBSEGADV | |
| Medicare Part D | 004336 | RX3982 (H3832) RX3983 (R7439) RX3984 (H1251) RX3985 (S3994) | MEDDADV |
| Medicare Part B | 004336 | RX3986 | ADV |
Note: Pharmacies may give each combination a unique label that can be easily accessed by pharmacy staff. An example of a unique label is in the far-right column.
Q. Who should pharmacies contact for technical assistance or assistance in setting up their systems?
A. Pharmacists can contact our pharmacy benefit manager:
- Medicare D: 1-866-693-4620
- QUEST (Medicaid): 1-800-364-6331
- Commercial: 1-800-364-6331
- Pharmacy benefit manager help desk hours of operation are 24/7/365.
Q. Now that my system is set up correctly, what do I need to do to submit a successful COB claim?
A. In addition to updating the software system, submitting a successful COB claim also requires using the correct corresponding NCPDP Other Coverage Codes:
| Code | OPR/OPAP | Description |
|---|---|---|
| 02 | OPAP Only | Payment Collected: Indicates secondary coverage; primary payer(s) paid something towards the claim. |
| 03 | Both | Claim Not Covered: Indicates secondary coverage; primary plan denied or rejected the claim. |
| 04 | OPAP | Payment Not Collected: Primary plan accepted or paid the claim, but claim cost is to be paid by the plan member. |
Q. What steps do I follow if a member has a primary HMSA private business plan with a secondary HMSA Medicare Part D plan?
A. See table below:
Coordination of Benefits
| Scenario | If the Primary is ... | If the Secondary is ... | RXBIN | RXPCN | RXGRP |
|---|---|---|---|---|---|
| Scenario #1 | HMSA, Blue Cross Blue Shield of Hawaii Commercial | N/A | 004336 | ADV | Varies |
| Scenario #2 | Other Commercial Insurance Plan | HMSA, Blue Cross Blue Shield of Hawaii Commercial* | 013089 | COMSEGADV | Varies |
| Scenario #3 | HMSA, Blue Cross Blue Shield of Hawaii Commercial | HMSA, Blue Cross Blue Shield of Hawaii QUEST* | 013089 | COMSEGADV | Varies |
| Scenario #4 | HMSA, Blue Cross Blue Shield Medicare Part D; or any other Medicare Part D Plan | HMSA, Blue Cross Blue Shield of Hawaii Commercial | 012114 | COBSEGADV | Varies |
*OPAP = Use Other Coverage Codes 02, 03 or 04 [in NCPDP Field # 308-C8]
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |