Can You Bill Secondary Insurance If Primary Denies?

When patients have both primary and secondary insurance, questions arise about handling claims when the primary insurer doesn’t cover the full cost. This article explains the process of submitting claims to secondary insurance following a primary denial, from understanding the initial denial to preparing and submitting the subsequent claim.

Understanding Primary Denials

A primary insurance denial means the initial insurer will not pay for some or all of a submitted medical service. This can occur for various reasons, such as the service not being covered by the policy, not being deemed medically necessary, or falling outside the network of approved providers. Other common reasons include missing prior authorization, claims filed past timely filing limits, incorrect coding, or a duplicate claim submission.

Understanding the reason for a primary denial is a first step before billing secondary insurance. The Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from the primary insurer serves as a record of how a medical claim was processed. This document is not a bill, but it details the provider’s charges, how much the primary plan covered, and any remaining amount the patient might owe. The EOB/ERA will contain specific denial codes and reasons that clarify why the primary insurer did not pay. It also shows amounts applied to deductibles or coinsurance, and the allowed amount for the services. Reviewing this document provides the information needed for any subsequent billing to a secondary payer.

Preparing Your Secondary Claim

Once the primary EOB or ERA is obtained, preparing the secondary claim involves transferring specific information from the primary EOB/ERA onto the secondary claim form. The primary insurer’s payment or denial reason, the patient’s remaining financial responsibility, and any relevant denial codes must be accurately noted.

For professional services, the CMS-1500 form is used, while institutional services use the UB-04 form. When completing the CMS-1500, specific fields, such as Box 11c, need to reflect the primary insurer’s payment or denial information. The form also requires an indication that it is a secondary submission. For the UB-04, relevant sections must be populated to show the primary payer’s details.

It is necessary to attach the primary EOB/ERA to the secondary claim form. This attachment provides the secondary insurer with a clear record of the primary payer’s adjudication. When attaching the EOB, ensure it is complete and legible. If the EOB contains information for other patients, black out any protected health information not pertaining to the current patient. Some systems allow electronic attachment of the scanned EOB, while for paper submissions, a physical copy is included.

Submitting to Secondary Insurance

After preparing the secondary claim and attaching the primary EOB/ERA, submit the claim to the secondary insurer. Electronic submission, often through Electronic Data Interchange (EDI) clearinghouses, is an efficient method. EDI streamlines the exchange of information between providers and insurance companies, helping to reduce errors and accelerate processing.

To submit electronically, the prepared claim data, including the primary EOB information, is transmitted via a clearinghouse. These systems provide error-checking and status tracking, which can help in managing the claim. Alternatively, claims can be submitted via direct mail, where the completed claim form and the primary EOB are sent to the secondary insurer’s designated address.

Verify the secondary insurer’s specific requirements, such as electronic payer IDs or mailing addresses. Maintaining detailed records of the submission, including tracking numbers for mailed claims or confirmation reports for electronic submissions, is a good practice. These records serve as proof of submission and can be useful for follow-up if needed.

Secondary Insurance Review

After the secondary claim is submitted, the secondary insurer begins its review process. This process involves Coordination of Benefits (COB), which determines how insurance companies cover medical expenses when an individual has more than one health insurance plan. COB rules establish which plan pays first (primary) and which covers the remaining eligible costs (secondary), preventing duplicate payments. The secondary payer takes into account the primary insurer’s payment or denial before processing the claim.

The secondary insurer’s review can result in full payment, partial payment, or another denial. If the secondary insurer makes a payment, they will issue their own EOB or ERA detailing their contribution. This document will outline the services covered, the amount paid by the secondary plan, and any remaining patient responsibility, such as amounts applied to a deductible or coinsurance.

Should the secondary claim be denied, a new EOB/ERA will be provided, explaining the reasons for their denial. Understanding this secondary EOB/ERA is important for determining any further action, such as appealing the decision or billing the patient for the remaining balance. Reviewing these documents helps to clarify how the claim was processed and any outstanding financial obligations.