How to Submit a Claim to Secondary Insurance

Having more than one health insurance plan can offer financial protection, helping to reduce out-of-pocket medical costs. When an individual has both primary and secondary insurance, claims are first submitted to the primary insurer. After the primary plan processes the claim and pays its portion, any remaining eligible balance can then be submitted to the secondary insurance for consideration. This process, known as coordination of benefits, ensures that both insurers work together to cover healthcare expenses without duplicating payments. This guide provides a step-by-step approach to navigate the secondary claim submission process.

Gathering Necessary Information and Documents

Before initiating a secondary insurance claim, collecting all relevant information and documents is a foundational step. The primary document needed is the Explanation of Benefits (EOB) from your primary insurance carrier. This document is a detailed statement outlining how your primary insurance processed your medical claim, including what was covered, what was denied, and the remaining balance.

The EOB is crucial as it contains specific data points necessary for the secondary claim. From the EOB, you will need to identify the allowed amount for services, the amount the primary insurer paid, and any remaining patient responsibility, such as deductibles, co-payments, or co-insurance. It also lists the procedure codes (CPT codes), diagnosis codes (ICD-10 codes), dates of service, and details of the healthcare provider. Original medical bills or statements corresponding to the EOB may be required as supporting documentation.

In addition to the primary EOB and original bills, you will need specific details about your secondary insurance policy. This includes your secondary policy number, group identification number, and the correct contact information for claims submission, such as a mailing address or website for online portals.

Completing and Preparing Your Claim

Once all the necessary information has been gathered, accurately complete the secondary insurance claim form and assemble the claim package. Obtain the specific claim form required by your secondary insurer, typically available on their website or by calling member services. Most individual claims use the CMS-1500 form, which is a standardized form.

Filling out the claim form requires transferring information from your primary EOB and medical bills. Provide your personal details, including your name, address, and secondary insurance policy information. The form also requires provider information, such as the healthcare facility’s name, address, and National Provider Identifier (NPI). The CMS-1500 form includes fields for primary insurance details, such as the payer’s name, policy number, and amount paid.

Include service details: dates of service, procedure codes (CPT codes), and diagnosis codes (ICD-10 codes). Indicate the billed amount, the amount the primary insurer paid, and the remaining balance. Always include a copy of the primary insurer’s EOB, as this document verifies the primary payment and is mandatory for secondary claim processing. Copies of original medical bills should also be included as needed.

Submitting Your Claim

After preparing your claim form and gathering all supporting documents, submit it to your secondary insurance carrier. Common methods include mail, online portals, or fax.

If submitting by mail, confirm the correct mailing address for claims processing. Send the claim using a method that provides proof of delivery, such as certified mail with a return receipt. Securely package the completed claim form along with all copies of supporting documents. Do not send original documents unless specifically requested.

For online portal submissions, navigate to your secondary insurer’s member portal. Upload digital copies of your completed claim form and the primary EOB. Save any digital confirmation or reference numbers for your records. For fax submission, find the correct fax number and obtain a transmission confirmation from your fax machine.

Following Up on Your Secondary Claim

After submission, monitoring your secondary claim’s status is important. Most insurance companies provide ways to track progress through online member portals or by contacting customer service. Online portals offer a claim status tool where you can enter your claim number or patient details.

Processing times for secondary claims range from a few weeks to a couple of months. Expect a response or an Explanation of Benefits (EOB) from the secondary insurer within 30 to 60 days of submission. This secondary EOB will detail what the secondary insurance paid and any remaining balance.

If you do not receive communication within the expected timeframe, or if you have questions about the secondary EOB, contact the secondary insurer directly. Have your claim number and submission date available when you call.