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Home » How to bill secondary insurance claims?

How to bill secondary insurance claims?

October 3, 2025 by TinyGrab Team Leave a Comment

Table of Contents

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  • How to Bill Secondary Insurance Claims: A Comprehensive Guide
    • Understanding Coordination of Benefits (COB)
      • Identifying the Primary and Secondary Insurers
      • Gathering Necessary Information
    • The Billing Process: Step-by-Step
      • Electronic Claim Submission (EDI) for Secondary Claims
      • Paper Claim Submission for Secondary Claims
    • Common Pitfalls and How to Avoid Them
    • Frequently Asked Questions (FAQs)
      • 1. What happens if the primary insurance denies the claim?
      • 2. Does the secondary insurance always pay the remaining balance?
      • 3. What is a “non-covered service” under the primary insurance?
      • 4. How do I handle claims with Medicare and a secondary insurance?
      • 5. What if the patient has two secondary insurances?
      • 6. How long do I have to submit a secondary claim?
      • 7. What are the common Claim Adjustment Reason Codes (CARCs) I should be aware of?
      • 8. How do I verify a patient’s secondary insurance coverage?
      • 9. What if the primary insurance payment is less than my contracted rate?
      • 10. What role does a clearinghouse play in secondary claim submission?
      • 11. Should I submit all claims electronically, even secondary claims?
      • 12. What resources are available to help me understand secondary claim billing?

How to Bill Secondary Insurance Claims: A Comprehensive Guide

Billing secondary insurance claims can feel like navigating a labyrinth, especially when you’re juggling a busy practice and complex patient coverage. However, mastering this process is crucial for maximizing reimbursements and ensuring your patients receive the financial benefits they deserve. So, how do you bill secondary insurance claims effectively? It boils down to meticulous documentation, proper coordination of benefits, and a thorough understanding of payer-specific guidelines.

Understanding Coordination of Benefits (COB)

The cornerstone of secondary claim billing is Coordination of Benefits (COB). This process determines which insurance plan has primary responsibility for paying a claim when a patient has coverage under more than one plan. The primary payer pays first, and then the secondary payer may cover remaining eligible expenses, depending on their policy terms.

Identifying the Primary and Secondary Insurers

This crucial first step dictates the entire billing process. Several factors determine primary payer status, including:

  • Birthday Rule: For dependents, the plan of the parent whose birthday falls earlier in the year is typically primary (month and day, not year). This rule often applies to children covered by both parents’ plans.
  • Court Orders: A court order specifying which parent is responsible for a child’s healthcare overrides the birthday rule.
  • Employee vs. Dependent Coverage: If a patient is covered under their own employer’s plan and also as a dependent under a spouse’s plan, their employer’s plan is generally primary.
  • Medicare and Employer Group Health Plan (EGHP): For individuals eligible for Medicare and covered by an EGHP, the EGHP is usually primary if the employer has 20 or more employees.
  • Workers’ Compensation and Liability Insurance: These are typically primary when the healthcare services are related to a work-related injury or accident.

Gathering Necessary Information

Before submitting a secondary claim, you need the following information:

  • Patient’s Primary Insurance Information: This includes the insurance company name, policy number, group number, and the patient’s relationship to the insured.
  • Primary Payer’s Explanation of Benefits (EOB): This document details the services billed, amounts allowed, amounts paid, and any patient responsibility (e.g., deductible, copay, coinsurance). The EOB is essential for submitting the secondary claim.
  • Patient’s Secondary Insurance Information: This includes the insurance company name, policy number, group number, and the patient’s relationship to the insured.
  • Demographic Information: Accurate patient details are always paramount.

The Billing Process: Step-by-Step

Once you’ve gathered the necessary information, follow these steps to bill the secondary insurance:

  1. Bill the Primary Insurance: This is the standard billing process for any insurance claim. Submit the claim with all required documentation and codes.

  2. Receive and Review the Primary Payer’s EOB: Carefully examine the EOB to understand how the primary insurer processed the claim. Note the allowed amounts, paid amounts, and patient responsibility.

  3. Prepare the Secondary Claim: Use the primary payer’s EOB to complete the secondary claim form.

  4. Include the Primary Payer’s EOB: This is a critical step. The secondary payer needs to see how the primary payer handled the claim to determine its responsibility. Attach a copy of the EOB to the secondary claim.

  5. Submit the Secondary Claim: Send the claim to the secondary insurance company according to their specific billing guidelines. This might involve electronic submission (EDI) or paper claims.

  6. Follow Up on the Claim: Track the status of the secondary claim to ensure timely processing. Contact the insurance company if you haven’t received a response within a reasonable timeframe (e.g., 30-45 days).

Electronic Claim Submission (EDI) for Secondary Claims

Many providers use Electronic Data Interchange (EDI) to submit claims electronically. When submitting a secondary claim via EDI, you’ll need to populate specific fields in the claim form with information from the primary payer’s EOB. This includes:

  • Claim Adjustment Reason Codes (CARCs): These codes explain why the primary payer reduced or denied payment.
  • Claim Adjustment Group Codes (CAGCs): These codes categorize the type of adjustment made by the primary payer (e.g., contractual obligation, patient responsibility).
  • Other Payer Claim Control Number: This is the claim number assigned by the primary payer.
  • Other Payer Paid Amount: This is the amount the primary payer paid on the claim.

Your clearinghouse or billing software should provide guidance on how to correctly enter this information.

Paper Claim Submission for Secondary Claims

If you’re submitting a paper claim, use the standard CMS-1500 form. The following fields are crucial for secondary billing:

  • Box 9: Enter the primary insurance policyholder’s name.
  • Box 9a: Enter the primary insurance policy number.
  • Box 9d: Indicate whether there is another health benefit plan.
  • Box 11: Enter the policyholder’s date of birth and sex.
  • Box 11d: Check the appropriate box to indicate whether this is also the patient’s insurance.
  • Box 19: This box is used for additional information. Indicate that the claim is for secondary insurance and include the primary payer’s name, claim number, and the amount paid. Attach a copy of the primary payer’s EOB to the claim form.

Common Pitfalls and How to Avoid Them

  • Inaccurate Primary Payer Information: This can lead to claim denials and delays. Verify insurance information at each patient visit.
  • Missing EOB: Failing to include the primary payer’s EOB is a common reason for claim rejection.
  • Incorrect Coding: Ensure accurate coding for all services provided.
  • Lack of Follow-Up: Neglecting to follow up on claims can result in lost revenue.
  • Not Understanding Payer-Specific Rules: Each insurance company may have its own unique guidelines for secondary claim billing. Familiarize yourself with these rules.

Frequently Asked Questions (FAQs)

1. What happens if the primary insurance denies the claim?

If the primary insurance denies the claim, you must determine the reason for the denial. Correct the issue (e.g., incorrect coding, missing information) and resubmit the claim to the primary insurer. Only after the primary insurer has processed the claim (even if denied) can you submit it to the secondary insurer.

2. Does the secondary insurance always pay the remaining balance?

No. The secondary insurance will review the primary payer’s EOB and its own policy terms to determine its payment responsibility. It may pay the remaining balance, a portion of it, or nothing at all, depending on factors like deductibles, coinsurance, and covered services.

3. What is a “non-covered service” under the primary insurance?

A non-covered service is a service that the primary insurance does not cover. The secondary insurance may or may not cover this service, depending on its own policy terms. Always check the patient’s specific plan details.

4. How do I handle claims with Medicare and a secondary insurance?

Medicare typically acts as the primary payer for beneficiaries aged 65 or older. However, there are exceptions, such as when the beneficiary is covered by an EGHP through their own or their spouse’s current employment. In these cases, the EGHP may be primary. Refer to the COB rules to determine the correct primary payer.

5. What if the patient has two secondary insurances?

In rare cases, a patient might have two secondary insurances. You’ll need to determine which secondary insurance is primary and which is tertiary, based on COB rules. The same process applies – bill the primary, then the secondary, and finally the tertiary insurance, attaching all previous EOBs.

6. How long do I have to submit a secondary claim?

Claim submission deadlines vary by insurance company. Check the secondary insurer’s guidelines to ensure timely filing. Missing the deadline could result in claim denial.

7. What are the common Claim Adjustment Reason Codes (CARCs) I should be aware of?

Common CARCs include:

  • CO 45: Charge exceeds fee schedule/maximum allowable amount.
  • CO 97: The benefit for this service is included in the payment/allowance for another service.
  • CO 151: Payment adjusted because the payer deems the information submitted does not support this level of service.

8. How do I verify a patient’s secondary insurance coverage?

Contact the secondary insurance company directly or use their online portal to verify coverage. Obtain details about deductibles, copays, coinsurance, and covered services.

9. What if the primary insurance payment is less than my contracted rate?

The secondary insurance will typically base its payment on the primary insurer’s allowed amount, not your contracted rate. Review your contracts with both insurers to understand the reimbursement terms.

10. What role does a clearinghouse play in secondary claim submission?

A clearinghouse can streamline the secondary claim submission process by validating claim data, ensuring proper formatting, and electronically transmitting claims to the insurance company. It can also track claim status and provide reporting.

11. Should I submit all claims electronically, even secondary claims?

Submitting claims electronically is generally faster and more efficient than paper claims. However, some insurance companies may require paper submission for secondary claims, especially when attaching EOBs. Check the payer’s guidelines.

12. What resources are available to help me understand secondary claim billing?

  • Insurance Company Websites: Most insurance companies have detailed information on their websites about billing procedures, COB rules, and claim submission guidelines.
  • Professional Associations: Organizations like the American Academy of Professional Coders (AAPC) offer training and resources on medical billing and coding.
  • Billing Software Vendors: Your billing software vendor can provide support and training on using their software to submit secondary claims.

Mastering the art of billing secondary insurance claims requires diligence, attention to detail, and a proactive approach. By following these guidelines and staying informed about payer-specific rules, you can ensure accurate and timely reimbursement for your services, ultimately benefiting both your practice and your patients.

Filed Under: Personal Finance

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