How to Bill Secondary Insurance Claims Correctly

Secondary health insurance provides additional coverage beyond a primary medical plan, helping to manage healthcare costs. It supplements the primary policy, covering care and services that the primary plan may not, or assisting with remaining balances such as deductibles, copayments, and coinsurance.

Understanding the Role of Primary and Secondary Insurance

When an individual has more than one health insurance plan, a process called Coordination of Benefits (COB) determines which plan pays first and which pays second. The primary insurance is always billed initially and pays its portion of the claim according to its coverage limits and rules. After the primary insurer processes the claim, any remaining eligible balance can then be submitted to the secondary insurance.

The secondary insurance then reviews the claim and the amount paid by the primary insurer, subsequently contributing its portion based on its own policy terms. This process ensures total payment for services does not exceed 100% of the actual cost, preventing duplicate payments. COB rules vary depending on the insurance company and specific plans involved. For instance, if you are covered by your own employer’s plan and as a dependent on a spouse’s plan, your employer’s plan is typically primary. For children covered by both parents’ plans, the “birthday rule” often applies, where the plan of the parent whose birthday falls earlier in the calendar year is primary.

Gathering Necessary Information for Secondary Claims

Before submitting a secondary claim, gather specific information and documentation. The primary insurer’s Explanation of Benefits (EOB) details how the primary claim was processed, indicating the amount paid, any adjustments, and the patient’s remaining responsibility. Key information to extract from the EOB includes the primary payment amount for each service, the patient responsibility (such as deductibles or coinsurance applied), and the primary claim’s reference number.

Obtain all relevant details for the secondary insurance policy. This includes the policyholder’s name, policy number, group number, and the secondary insurer’s payer ID. If submitting a paper claim, the correct mailing address for the secondary insurer is also required. Verifying the patient’s secondary insurance coverage and its scope ensures smooth processing. This comprehensive collection of information from both the primary EOB and the secondary policy is fundamental for accurate secondary claim submission.

Submitting the Secondary Claim

Secondary claims can only be billed after the primary payer has processed its claim and a response has been received. Common methods for submission include mailing a paper claim or submitting electronically through an online portal or clearinghouse.

For paper claims, a standard claim form, often referred to as the CMS-1500, is used. When completing this form for secondary billing, specific fields must accurately reflect the information from the primary EOB. For example, Box 4 should contain the insured’s name if different from the patient, and Box 6 should indicate the patient’s relationship to the insured. Box 11 is used to identify the primary insurance information, including the policy number and the primary payer’s identification number.

It is essential to attach a copy of the primary EOB to the paper claim. If the EOB contains information on other patients, it is important to redact that protected health information before submission. For electronic submissions, the process is similar to primary claims, where the primary adjudication information is embedded in the electronic data interchange (EDI) file. Online portals typically allow for direct input of the gathered information and the uploading of the primary EOB.

Following Up and Troubleshooting

After submitting a secondary claim, tracking its status is an important step. Many insurance companies offer online portals for checking claim status, or you can contact the insurer directly by phone. This proactive approach helps identify any potential issues early in the process.

Secondary claims may be denied for several reasons. Common issues include missing or incorrect primary EOB information, errors in coordination of benefits (COB) data, or failure to meet timely filing limits. Timely filing limits for secondary claims can vary, often ranging from 90 to 180 days from the date of the primary carrier’s EOB. If a claim is denied, review the denial reason and take corrective action. This might involve submitting an appeal with additional documentation or corrected information. The appeal process typically has its own timely filing limits, which can be around 120 days from the date of the initial determination.