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Streamline benefits coordination

Health plans face many challenges when trying to identify and validate liable parties and primary policy coverage, including:

Time, staffing and budget constraints
Lack of access to eligibility records from other insurers
High administrative costs associated with member attestations and staff validations
Reliance on abrasive post-pay recovery and Medicaid reclamation rather than cost avoidance

But inaccurate coordination of benefits often leads to higher administrative and medical costs as well as member and provider abrasion. Optum® Coordination of Benefits is designed to deliver accurate eligibility data to identify and validate primary coverage as soon as member enrollment.

Identify and validate primary policy coverage

We prospectively and retrospectively identify and validate primary coverage, reducing rework, costs and provider abrasion.

AI-powered primacy validation

We use machine learning models and our expansive set of primacy data to coordinate benefits, helping maximize healthcare payment accuracy.

Validate matches with human expertise

Potential policy matches are validated by Optum subject matter experts with over 99% accuracy.*

Avoid future overpayments

We notify clients as soon as other primary coverage is confirmed, enabling them to avoid future overpayments.

Cost containment across the payment lifecycle

Built on a foundation of AI and machine learning models, our Coordination of Benefits solutions help health plans increase payment accuracy.

Prospective Coordination of Benefits

Reviews member eligibility files on an ongoing basis and returns updated files with additional coverage when identified.

Pre-Pay Coordination of Benefits

Reviews each incoming claim and identifies and validates primary member coverage prior to payment.

Post-Pay Coordination of Benefits

Reviews paid claims to detect and recover overpayments due to coordination of benefit errors.

Member Management

Verifies Medicaid eligibility and dual status in real time.

Medicaid Reclamation

Reviews paid Medicaid claims to detect and recover overpayments due to coordination of benefit errors.

Comprehensive eligibility data for improved benefits coordination

Data is refreshed daily, enabling Optum to identify members who have other primary coverage with efficiency and approximately 99% accuracy.* This helps health plans immediately update their eligibility systems and prevent future overpayments.

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Frequently asked questions about third-party liability solutions

When an individual is enrolled in more than one health plan, third-party liability establishes which plan is responsible for paying first and which pays after. This determination is based on standardized rules — such as primary versus secondary coverage, member status and plan type — so that the correct payer handles the claim in the right order.

Proper coordination prevents duplicate payments, helps minimize administrative errors, and promotes claims payment accuracy. When executed effectively, it can also help reduce unnecessary provider follow-ups and allow members to receive benefits according to each plan’s coverage guidelines.

Effective benefits coordination plays a major role in cost containment and risk mitigation. By clearly establishing payment order and sharing relevant coverage information, health plans can avoid common sources of financial leakage such as overpayments, underpayments and erroneous reimbursements.

Strong coordination practices also help reduce fraud exposure by verifying members’ true coverage status. Beyond direct cost savings, plans benefit from fewer disputed claims, improved operational efficiency and more consistent application of policy rules.

Health plans often rely on a combination of data-driven and member centric methods to identify individuals who may be covered under multiple policies. These methods include cross plan data matching, periodic member surveys, eligibility verification at key touchpoints and analyses of claim histories that reveal patterns suggestive of overlapping coverage. Integrating these techniques helps plans proactively verify benefits, help reduce payment errors and maintain accurate enrollment data.

Accuracy can improve when health plans adopt strong data management practices, modern eligibility verification tools and streamlined communications with other health plans and providers. Standardizing member information, reducing manual data entry, and leveraging automated checks help validate primary and secondary coverage in real time.

Additionally, collaborative data sharing between health plans can enhance visibility into overlapping benefits, allowing each plan to adjudicate claims more appropriately while reducing administrative burdens.