MedicaidAdministrativeHigh impact
[Ohio] ODM clarifies Third-Party Liability (TPL) and Coordination of benefits (COB)
Anthem BCBS·OH·Provider Bulletin
Effective date
Jun 4, 2026
We identified it
Jun 5, 2026
Summary
Ohio Medicaid (ODM) has clarified strict Third-Party Liability (TPL) and Coordination of Benefits (COB) requirements, mandating that providers must make documented reasonable efforts to obtain payment from all liable third-party payers before billing Anthem. Providers must meet specific conditions (claim denial, multiple submission attempts, prior service verification, or documentation of no coverage) to satisfy TPL requirements. Failure to comply may result in claim denials or recoupments.
Action Required
Effective immediately: (1) Billing team must update TPL verification workflow to document all submission attempts to third-party payers before billing Anthem, maintaining records of submission dates. (2) Implement one of four acceptable TPL satisfaction methods: obtain TPP claim denial with remittance advice, submit claims to TPP at least 3 times within 90 days with documentation, verify no coverage change from prior 365-day service, or retain written TPP communication/system output confirming no applicable benefit. (3) Ensure all TPL claims to third-party payers use accurate, timely coding. (4) Train billing staff to append appropriate COB coding when billing Anthem after TPL efforts are exhausted. (5) Establish documentation retention process for all TPL billing efforts (submission dates, denials, eligibility verification, no-coverage documentation). (6) Designate staff to maintain supporting documentation for audit/recoupment defense. Consequences: Claims will be denied or subject to recoupment if TPL requirements are not met and documentation cannot be furnished upon request.