TIER 2 · COORDINATION OF BENEFITS · AUDIT WORKSHEET
Five COB Terms Decide How a Single Claim Coordinates.
The Flag Is Rarely Audited. The Worksheet Checks It.
A 2-page printable worksheet PBS uses across 100s of PBM contract reviews annually. Free download. Sent to your inbox.
Three audit passes on coordination of benefits
Five COB terms that decide how a claim coordinates
Where copay-program economics actually live
The COB flag most plans never check
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A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
Audit the COB Flag
Coordination of benefits is where copay-card and accumulator economics actually live. How a claim coordinates decides whether the manufacturer's assistance benefits the member, the plan, or the PBM.
PASS 01
Read the Five COB Terms
Five terms govern coordination of benefits: the primary-payer rule, the carve-out coordination, the copay-program treatment, the secondary-claim logic, and the recovery clause. Each decides how a single claim splits.
PASS 02
Find the Copay-Program Money
Coordination of benefits is where copay-card and accumulator economics actually live. How a claim coordinates decides whether the manufacturer's assistance benefits the member, the plan, or the PBM.
ACTION PLAN
This Quarter's Action Plan
Run the three passes, trace how a sample of coordinated claims actually split, and require COB reporting. The clause nobody audits is the clause worth auditing.