Understanding The Billing Process: Navigating Primary And Secondary Insurance Coverage

When a client has multiple insurance coverages, the first payer responsible for the remittance of the claim is known as the primary insurance, and the second payer is known as the secondary insurance. The client does not get to choose which insurance is their primary insurance—this is determined by the insurance payers. Typically, the insurance under which the client is the primary subscriber is the client's primary insurance. For example, if a client has insurance coverage from their employer but also has coverage through their spouse's employer, the insurance coverage through their own employer would be primary and the coverage under their spouse's plan would be secondary. Once the primary payer has remitted the primary claim, the secondary claim can be sent to the secondary payer.

Primary insurance is billed first

When a patient has two insurance plans, one is considered primary and the other is secondary. The primary insurance is billed first and the secondary insurance is billed after.

The primary insurance is the plan that claims will be billed to first. The claim will be processed according to the patient's insurance plan with the primary insurer and payments will be made according to their benefits. Once the primary payer has remitted the claim, it can then be sent to the secondary payer.

It is important to confirm which insurance plan is primary before submitting a claim. Healthcare providers cannot submit a claim to both insurance companies at the same time. The primary insurance is usually the plan under which the client is the primary subscriber, for example, the patient's own employer's insurance. However, there are exceptions and rules that determine which plan is primary. For example, in the case of a child covered by both parents' plans, the parent whose birthday falls first in the year has the primary insurance plan.

The secondary insurance plan may then cover additional costs, such as the client's copay or deductible. However, the secondary insurance company may not always pay the remaining balance of the bill.

Primary insurance is responsible for the contracted rate

When a client has multiple insurance coverages, the first payer responsible for the remittance of the claim is known as the primary insurance. The primary insurance is responsible for their portion of the contracted rate as per the client's insurance plan. The primary insurance policy is the policy that claims will be billed to first. The claim will then be processed according to the patient's insurance plan with the primary insurance and payments will be made according to their benefits.

The client does not get to choose which insurance is their primary insurance; this is determined by the insurance payers. In general, the insurance under which the client is the primary subscriber is the client's primary insurance. For example, if a client has insurance coverage from their employer but also has coverage through their spouse's employer, the insurance coverage from their own employer is likely to be primary and the coverage under their spouse's plan is secondary.

Once the primary payer has remitted on the claim, the claim can then be submitted to the secondary payer. The secondary insurance will often cover the client's copay or sometimes more. The secondary insurance payer will often cover a portion of the remaining balance, which often includes the client's copay. The secondary insurance pays some or all of the costs left after the primary insurer has paid (e.g. deductibles, copayments, coinsurances). For instance, if Original Medicare is the primary insurance, the secondary insurance may pay for some or all of the 20% coinsurance for Part B-covered services.

It is important to confirm which insurance is the client's primary coverage before submitting a claim. Healthcare practices cannot submit a claim to both insurance companies at the same time. To figure out which is the primary insurance, the coordination of benefits (COB) must be checked. This is a provision in an insurance policy that specifies what each insurer is responsible for paying for. While there are a number of rules and variables that can affect which insurer is the primary payer, there are some general standards to know. Usually, a patient's coverage from their own employer will be primary insurance, and their coverage from a spouse or parent will be secondary insurance.

Secondary insurance covers the remaining balance

When a client has multiple insurance coverages, the first payer is known as the primary insurance, and the second payer is known as the secondary insurance. The client does not get to choose which insurance is their primary insurance coverage; this is determined by the insurance payers. Typically, the insurance plan under which the client is the primary subscriber is deemed the primary insurance. For example, if a client has insurance coverage from their employer and their spouse's insurance coverage, the insurance coverage through their employer is likely to be the primary insurance, and the coverage under their spouse's plan is the secondary insurance.

The primary insurance is responsible for its portion of the contracted rate as per the client's insurance plan. The secondary insurance will often cover the remaining balance, including the client's copay. There are many instances in which a client might have more than one form of health insurance coverage. For example, a client may have insurance coverage through their employer and also have coverage through their spouse, meaning that they have both primary and secondary insurance.

If a client has two insurance coverages, and one of those plans is TriCare or Medicaid, it is likely that the TriCare or Medicaid coverage is secondary. Medicare plans can be either primary or secondary coverage, depending on the client's situation. If there is uncertainty about which insurance coverage is a client's primary or secondary insurance, it is recommended to reach out to the payers to find out.

The billing process for primary and secondary insurance comes in stages. First, the claim is submitted to the primary payer, and once the primary payer has remitted the claim, it can be submitted to the secondary payer. It is a common mistake to think that primary and secondary insurance claims are billed simultaneously.

Secondary insurance is billed after the primary payer remits the primary claim

When a client has multiple insurance coverages, the first payer responsible for the remittance of the claim is known as the primary insurance, and the second payer is known as the secondary insurance. It is important to note that the client does not get to choose which insurance is their primary insurance coverage; this is determined by the insurance payers. Typically, the insurance under which the client is the primary subscriber is the client's primary insurance.

When billing for primary and secondary claims, the primary claim is sent before the secondary claim. This means that once the primary payer has remitted the primary claim, you can then send the claim to the secondary payer. This is a common mistake, as some believe that primary and secondary insurance claims are billed simultaneously. However, this is not the case, and the process occurs in stages.

After the primary payer has remitted the primary claim, the claim can be sent to the secondary payer. The secondary insurance payer will often cover a portion of the remaining balance, which may include the client's copay. When sending the claim to the secondary payer, it is crucial to include the total billed amount of the claim, the amount the primary insurance paid, and the reasons why the primary payer did not pay the claim in full. This information is essential for the secondary payer to understand the remaining balance and make their payment.

In summary, it is important to understand the difference between primary and secondary insurance when billing insurance claims. By following the correct billing process and providing the necessary information to the secondary payer, you can successfully submit secondary insurance claims and receive the appropriate reimbursement for your clients' medical expenses.

Common reasons for secondary claim rejections

When a client has multiple insurance coverages, the first payer is known as the primary insurance, and the second payer is known as the secondary insurance. It is important to note that the primary and secondary insurance claims are not billed simultaneously. The primary claim is sent first, and once the primary payer has remitted the claim, it is then possible to send the claim to the secondary payer.

• Missing or Invalid Secondary Claim Information: This rejection occurs when the total billed amount of the secondary claim does not match the primary payment amount and claim adjustments. Secondary payers want to see the total billed amount, the amount paid by the primary insurance, and the reasons for any discrepancies. To avoid this rejection, ensure that your claim includes adjustments to indicate the categories of the remaining balance.
• Duplicate Claims: Duplicate claims occur when the same claim is submitted more than once. To prevent this, always check the status of a claim before resending and verify the initial denial reason. Do not resubmit claims while identical claims are still pending or when a partial payment has been made.
• Eligibility: Eligibility rejections or denials can arise from inaccurate or incomplete patient information. To avoid this, ensure that the patient provides accurate information, obtains copies of their insurance card, and verifies eligibility dates and benefit coverage.
• Missing or Invalid Payer ID: This rejection occurs when the payer ID is missing or invalid for the type of claim (institutional, professional, or dental). Always use the correct payer ID and include a secondary payer ID if necessary.
• Missing or Invalid Billing Provider National Provider Identifier (NPI): This rejection is due to a missing or invalid NPI for the billing provider. To resolve this, confirm that the billing provider is credentialed with the payer and enrolled with the clearinghouse for electronic claim submissions. Ensure that the correct group or individual NPI and tax ID are credentialed.
• Invalid Diagnosis Code: This rejection occurs when an invalid or outdated diagnosis code is used. To avoid this, use the most updated codes and ensure that the diagnosis code is active for the date of service and consistent with the procedure being performed.

Frequently asked questions