Will Secondary Pay If Primary Insurance Denies?

Navigating health insurance claims can feel complicated, especially when a primary insurer denies coverage. Many with multiple health plans wonder if secondary insurance will cover costs. Understanding primary and secondary insurance roles provides clarity. While intricate, grasping these concepts empowers individuals to manage healthcare expenses.

Understanding Primary and Secondary Coverage

When an individual has more than one health insurance policy, the concept of primary and secondary coverage determines the order of payment. Primary insurance pays first, covering its share of costs according to its terms. Secondary insurance then acts as a supplemental policy, considering what remains after the primary insurer processes the claim. This process is known as coordination of benefits (COB).

Coordination of benefits rules prevent overpayment or duplicate payments. These rules establish which plan is primary and secondary, ensuring efficient claim processing. Common scenarios include Medicare with an employer plan, coverage by an employer’s and a spouse’s plan, or dual coverage due to age or disability. After the primary insurance processes a claim and pays its portion, the secondary insurance reviews the remaining balance and may cover some or all, depending on its benefits and limitations.

Common Reasons for Primary Insurance Denials

A primary insurance company may deny a claim for various reasons, often unrelated to secondary coverage. One frequent reason is the service was not medically necessary. Another common cause for denial occurs when a service is not a covered benefit under the primary insurance plan. This can happen if the policy has specific exclusions for certain procedures or treatments.

Claims can also be denied if the healthcare provider is out-of-network for the primary insurer, leading to non-coverage or higher out-of-pocket costs. A lack of prior authorization for certain procedures, such as specific scans or surgeries, can also result in a denial, as many plans require pre-approval. Administrative errors like incorrect coding, incomplete information, or duplicate claims are frequent culprits, often stemming from billing mistakes.

When Secondary Insurance May Pay After Primary Denial

Secondary insurance may pay after a primary denial under specific circumstances, but it does not automatically cover all costs. If the primary insurance paid partially, leaving a balance for deductibles, copayments, or coinsurance, the secondary insurance might cover some or all of that remaining amount. This depends on the secondary plan’s benefit structure and its coordination of benefits rules. For example, if the primary plan covered 80% of a service, the secondary plan could potentially cover a portion of the remaining 20%.

If the primary insurer denied a claim because the service was not covered under its specific plan, the secondary insurance might still pay if that service is a covered benefit under the secondary plan. This scenario is relevant for services like certain therapies or specialized treatments that one plan may exclude but another includes.

Similarly, if the primary plan denied coverage because the provider was out-of-network, the secondary insurance might still pay if that provider is in-network for the secondary plan, or if the secondary plan offers out-of-network benefits.

Secondary insurance applies its own coverage rules and medical necessity criteria. If the primary insurance denied a claim because the service was not medically necessary, or due to fraud, the secondary insurer is unlikely to provide coverage unless its medical necessity criteria are significantly different. Secondary plans are designed to fill gaps in primary coverage or reduce out-of-pocket costs, not to cover services broadly considered uncovered or inappropriate.

Steps After a Primary Denial

A primary insurance denial requires immediate action to understand the situation and pursue potential coverage. First, carefully review the Explanation of Benefits (EOB) document from your primary insurer. This document details the services billed, the amount covered, and the specific reason for the denial. Understanding the exact reason, such as “not medically necessary” or “out-of-network,” is essential for subsequent steps.

After reviewing the EOB, contact your primary insurance company directly to seek clarification on the denial. This call can help confirm the reason for denial and identify any administrative errors that might be easily corrected. If you believe the denial was incorrect, you have the right to appeal the primary insurer’s decision. The appeal process involves submitting a written request, often with supporting documentation like a letter from your healthcare provider explaining the medical necessity of the service.

Once the primary insurer’s process is complete, whether through payment or a final denial, you can then submit the claim to your secondary insurance. You will need to provide the secondary insurer with the EOB from your primary plan, along with the original claim information. This allows the secondary insurer to review what the primary plan covered or denied and determine its own payment responsibility. After submission, anticipate a processing period, and you will receive another EOB from the secondary insurer detailing their payment or denial decision.