Filing Secondary and Tertiary Insurance Claims

25 Jul

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When we initial started our medical billing organization in 1994 I had no earlier expertise at billing any healthcare claims, let alone secondary and tertiary. (You mean some people have 3 insurances?) I knew nothing. In fourteen years of billing I’ve discovered really a bit and I see from inquiries in our forum that a lot of newcomers do not realize secondary and tertiary claims billing at all.

1st of all, how does anybody get two or 3 policies and which is determined main? If a husband and a wife each function (who does not?) and they are each covered by health insurance by their employers, they may each have family policies so they are each covered below each and every other folks program. One would be main and the other secondary. Now if 1 of this couple (a few years ago we would have assumed that it would only be the husband) had previous military encounter and carried more than their Tricare military insurance, that would be the third payor (if there was a balance left).

Which organization is main and which one particular is secondary is determined by 1 of a couple distinct approaches. 1st of all, if a individual is functioning and they carry insurance, that insurance is main (unless they have Medicare and their employer has much less than 100 staff). If a particular person is retired and has Medicare but the spouse performs and carries a family policy, then the spouse’s program would be principal and the Medicare would be secondary.

There is no way to cover every situation but fundamentally whether or not or not the particular person or the spouse is operating can determine the order. For dependents (normally youngsters) some go by the “birthday rule” meaning that whichever parents birthday falls initial in the year is main. Of course with all of the divorce out there at times the order of insurance is determined by a court order.

When a patient is noticed by a provider the claim is sent on a CMS 1500 kind to the principal insurance carrier either electronically or on paper. Electronically it can be sent either directly to the insurance carrier by special computer software or via a service or by means of a clearing property. When sent on paper it straightforward indicates the claim is printed to a paper CMS 1500 kind and sent by way of the mail. What ever the situation is, it is crucial that you know the order of the policies.

When the primary insurance carrier pays their share of the claim it is then submitted to the secondary insurance firm if the patient has one. Secondary claims can also be sent electronically and on paper. Medicare is mandating electronic submissions even on secondary claims. When submitted electronically all the data from the eob (explanation of benefits) is entered into the claim info and submitted to the secondary insurance carrier.

When the secondary is submitted on paper, the claim is printed out once more on a cms type and a photocopy of the eob is attached. If other patients are listed on the eob, their private details need to be hidden. Several offices use black markers (we get in touch with them smelly pens) to draw through the undesirable information. I’ve set up a bunch of numerous width strips of white cardboard that we slide into clear report covers to cover the undesirable info before we photocopy. We only do this with firms that are not however accepting electronic submissions.

If there is still a balance after the secondary insurance carrier pays their share, the claim is sent on to the third carrier. It is printed out once again on a cms form and copies of the eobs of each the principal and the secondary insurance carriers are attached.

Whenever you send secondary and tertiary claims on paper, make certain the photocopies you attach are clear, easy to read, and for the proper date of service. Several insurance carriers scan the eobs which lightens them a small. If the copy you submitted was currently light, by the time the claim is processed it may be sent back to you as unreadable. It takes a lot far more time to uncover the original eob and resubmit a claim than it does to get it right the very first time.

Secondary and tertiary claims can sometimes look like a discomfort to get paid – specially due to the fact they can be for a extremely little amount of funds. It is nevertheless crucial to file and track these claims to maintain your receivables under handle. It could not seem like a lot of funds but it adds up. If you have a program for submitting them it really is not that poor.

21 Responses to “Filing Secondary and Tertiary Insurance Claims”

  1. Fredrick January 9, 2013 at 3:24 am #

    why dialysis patient who’re enrolled with cobra after 30 several weeks their coverage is going to be dropped? Would they ‘t be covered for his or her secondary insurance beside using Medicare insurance.

  2. Shiloh January 12, 2013 at 12:10 am #

    I known as to have an appt.and something of his receptionist stated I needed to pay a minimum of $55. before he could see me. I do not pay anything up front, because my secondary insurance accumulates the 20% that my primary inches. does not pay. I had been very upset, but Yes, it isn’t my physician saying this. It’s the new practice administrator making these new rules. If there is something on paper provided to the patients?

  3. Karlyn February 19, 2013 at 4:47 pm #

    This is my second pregnancy. My first one ended in a miscarriage in the first trimester. I’m not sure when. When I go to my 1st prenatal appointment I will be 7 weeks & 5 days pregnant. Are they likely to do an ultrasound because of my previous miscarriage? I’m not sure how many u/s’s my insurance will cover, but I’m under a primary and secondary insurance. I don’t know if that changes anything or not.

  4. Jacquline March 28, 2013 at 10:02 am #

    Hi I graduated from College a couple years ago and was offered dental at my new job, currently I am 24.

    I need my wisdom teeth out, badly. So I want to know if i sign up for my company dental plan which covers 50% of the cost, can i also use my parents to cover the other half as a secondary insurance? I know Obama’s law gave students health coverage till they’re 27 so does this cover it?

  5. Milan March 29, 2013 at 4:17 pm #

    I have two jobs and two dental insurance plans. For example, if the doctor issues 1000 for a procedure, the primary insurance 800 and the second 900. (The doctor is out of network for secondary insurance) Both insurances cover 50% ($450 all together) How much am I supposed to pay the doctor?

  6. Shirley April 1, 2013 at 2:41 am #

    I have a primary and a secondary insurance. One of my medical providers is saying they ignore or do not have to honor the seondary contacted discounted amount and only look at the primary insurance contacted amount. All they accept from the secondary is the payment they make. Do they have that right or it is a regualted rule?

  7. Noel April 2, 2013 at 11:50 pm #

    I work in a private practice Urgent Care Center. We do not participate with Medicaid. If a patient comes in and her secondary insurance is medicaid, can we refuse to see the patient?

  8. Zelda April 9, 2013 at 5:44 am #

    My father has me under his insurance plan and I also have medical in the state of California. My son’s medical worker signed me up for medical when I became pregnant with my second child. Also, can I use medical as secondary insurance to pay the remaining balance of my hospital bill?

  9. Karly April 24, 2013 at 6:10 pm #

    I live in NY, and am eligible for Medicaid.

    However, I have private insurance now, but it doesn’t cover much, including prescriptions and is subject to large deductibles. Is it possible to have both at the same time, and use Medicaid as secondary insurance? I found some answers that say yes, but it doesn’t specify the state.

  10. Waneta May 25, 2013 at 1:01 am #

    i have travel insurance with a company but don’t think i’m covered as its couple insurance and i live at a different address to my partner, so i took out another policy for us – as long as we only claim on the new policy if we need to – is is ok to have 2 travel insurance policies?

  11. Robin May 25, 2013 at 11:50 am #

    What are the pros and cons to his new health plan? I understand we can keep our private health plan if we choose however, if we are paying for these government plans any way I would probably go to the government plan. I know we all need health coverage but what will it really be? For example: I know we have county hospital and doctors now, will we all go to that, I am assuming there will be more of them or will we be able to go to private doctors and hospitals and file our claims on our new government health plan. Will it be like HMO, that is managed by the government? Do we pay out of pocket or is it included in our taxes we already pay? Will it be the same coverage that Medicaid and Medicare supply or not?

  12. Lewis May 25, 2013 at 6:24 pm #


  13. Alayna June 12, 2013 at 2:26 am #

    My husband is covered under my empolyer’s plan, as well as a standing policy that he has held for years. We keep it because his health isn’t great and if I would loose my job, he would need to be covered and would have a hard time getting a new policy with his conditions.

    The doctors have been giving him a hard time because he is under 2 policies (he only submits to one at a time).

    Can you be covered by 2 policies, but only submit claims to 1?

  14. Brigida June 13, 2013 at 5:58 am #

    Any tips on interviewing for an insurance claims position? I currently work in sales and am interviewing for a claims position with a different company. If anyone has or currently works for Amica that would be great! Any tips on their testing would also be helpful.

  15. Mahalia June 14, 2013 at 6:01 pm #

    Wat is the nature of the job and how it works?

  16. Kermit June 15, 2013 at 8:16 am #

    My husband and I are thinking of having another child and we are looking at getting secondary insurance for this. I am just wondering if the money is worth it to get the insurance.

  17. Shena June 24, 2013 at 10:38 am #

    Any help would be very very much appreciated.

    Dear manager of centrelink,
    I am writing to you because I feel that I have been treated unfairly and not taken seriously simply because of my age. In early December I applied for unreasonable to live at home. My mum kicked me out and I had nowhere else to go. I applied for housing and am currently waiting for a public housing flat. I must pay 25% of my income for rent. I believed that with my unreasonable to live at home allowance I would manage, however my application was not approved. This will mean, with only $206 coming in each fortnight,(from the regular amount of youth allowance that I now receive)that it is going to be very difficult to even be able to afford enough food for the fortnight, let alone be able to keep up with bills, or be able to afford some furniture. I believe this to be incredibly unfair as the only reason my application was not approved is because of a misunderstanding between the centrelink social worker and my mother. When I asked why my application had not been approved, the social worker told me that my mother had said I was welcome to come home, when this was not at all the case. After speaking to my mother about this, she told me to ask the social worker to call her back so she could clear this up as she thought there might have been a bit of a language barrier issue, but he refused to make that effort and believed he was definitely right about what she had said. The fact is, my mother has told me she does not want me to be living at home and I am not allowed to go back. I have just started college and have been very excited to get into my studying this year, but with only $206 a fortnight I will have no choice to get a job. My study hours are very long considering I’m doing a full-time tertiary year 11 and 12 package, as well as a full-time community services certificate IV through correspondence. I will have to drop out of school to get a full time job, which will make it very unlikely that I will ever be able to finish my studies or get out of public housing, or I will have to continue couch surfing between friend’s houses because I won’t be able to afford rent. I understand that to the social worker my reasons for it being unreasonable to live at home may have been small compared to a lot of other people my age who have serious issues at home which definitely make it not possible to live at home. My situation may not be as serious, but if I am not allowed to go home and my mother will not let me stay there, then please tell me how is it at all reasonable for me to live there?! I simply can’t live there, which means I have to find somewhere else to live. $206 per fortnight is definitely not enough to be able to afford rent anywhere! My mother did not just tell me to leave after we’d had a silly fight, my issues with her go far deeper than that.
    I would also like to state that living on the streets the past few months has proved to be very dangerous for me and I truly fear for my safety. On a number of occasions I have had to choose between staying with people I barely know, and sleeping on the streets. I have been badly physically assaulted twice. A police man approached me one day after seeing me badly beaten up and spoke to me, off the record, about what had happened. The policeman knew the family who had assaulted me and he told me that he feared if I reported the incidents that the retribution by this family may be a lot worse than the initial assaults. When my phone was stolen, also by this same family, (a few weeks before I was kicked out of home) I made a report to the police so that I could claim insurance and the police that I spoke to on that occasion also advised me that if I pressed charges the retribution would probably be much worse than what it was worth to charge them. I try very hard to avoid them wherever I go and I try not to walk anywhere anymore, or go anywhere by myself. However, seeing as most days I spend trying to find a place to sleep that night, I am often going from one side of Canberra to the other trying to get to another friends house and it is hard to avoid them.
    I am very mature for my age as I have had to deal with a lot throughout my life. I handle money wisely and I know very well how to look after myself as even though I have lived in the same house as my mother my whole life, I have still lived quite independently from her; cooking for myself; finding my own transport; paying for clothes; toiletries, etc..
    I am definitely capable of taking care of myself and my money when I move into my own place, if I wasn’t then housing would not have approved my application. The Junction Youth Health Service provided letters of support for getting my own flat. I have attended the service for quite some time now and they understand that many of the issues in my life would be fully resolved by moving into my own place.
    Since my application was not accepted, I have had to borro

  18. Jefferey July 4, 2013 at 11:18 am #

    By a recent study, This is the list

    1. Barbados
    2. St.Kits and Nevis
    3. Bahamas
    4. Trinidad and Tobago
    5. Antigua & Barbuda
    6. Grenada
    7. Dominica
    8. St. Lucia
    10 . St. Vincent and the Grenadines

    These are the top caribbean countries in the Human Development Index.
    The HDI (Human Development Index/Indicator) combines normalized measures of life expectancy, literacy, educational attainment, and GDP per capita for countries worldwide. It is claimed as a standard means of measuring human development—a concept that, according to the United Nations Development Program (UNDP), refers to the process of widening the options of persons, giving them greater opportunities for education, health care, income, employment, etc. The basic use of HDI is to measure a country’s development.

    The HDI combines three basic dimensions:

    * Life expectancy at birth, as an index of population health and longevity
    * Knowledge and education, as measured by the adult literacy rate (with two-thirds weighting) and the combined primary, secondary, and tertiary gross enrollment ratio (with one-third weighting).
    * Standard of living, as measured by the natural logarithm of gross domestic product per capita.

  19. Shannon July 4, 2013 at 11:18 am #

    Americans are always quick to say everything is communist like free healthcare and free tertiary education. That’s why most American college graduates are burden down still paying off student debts and some can’t even get jobs. Many Americans also have to pay through their teeth for health insurance and many can’t pay for life saving operations. I remember reading about a guy who robbed a bank of a dollar just so he could go to jail and get health insurance. All citizens worldwide are expected to pay taxes to their respective governments so why shouldn’t these governments provide free education and healthcare to their citizens?

  20. Brady August 23, 2013 at 6:10 am #

    I know it’s sometimes a good idea to sometimes have secondary insurance, to fill in the gaps that some policies may fill. My wife and I work for the same company, so this is not really the case.

    Can we both have the same policy and stack the benefits, or is it like paying twice for one batch of coverage?

  21. Kymberly September 19, 2013 at 5:10 am #

    The situation: Recently disabled senior,( employed full time up until about 9 months ago when he was diagnosed with alzheimers disease and fully insured under a group health plan by United Health Care) is in need of full time nurse care/hospice care. He is currently in home hospice and a nurse/caregiver comes to the house 3x a week to bathe him. He suddenly needs full time care and will no longer be insured under the group healthplan from his previous employer in another 6 weeks. He has the option of Medicare A, Medicare B and/or coverage due to being an American Veteran

    Should he use Medicare or the Veterans coverage as his primary provider? How do you go from a private group health plan to medicare or being covered as an American Vet?

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