Wednesday, 6 February 2013

How to submit the claims after primary insurance ?

This is another interesting area where lot of automation is required in the software.

Before going to Secondary insurance, we should understand the Claim Life cycle as shown in the following Flow chart:





Once the primary insurance carrier pays their share of the claim it is then submitted to the secondary insurance company 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 information from the eob (explanation of benefits) is entered into the claim information and submitted to the secondary insurance carrier.

Now days, most of the insurance company accepts electronically if they are secondary payer. Here the term “Secondary payer” does not really mean the number 2. Any insurance after the primary is normally called as Secondary payer, but as per the patient, it may be in the third position. As per new 5010 documentation, it supports the submission of claims containing up to 11 payers (destination payer plus 10 non-destination payers).

Some times, the primary insurance itself forward the claim to secondary insurance and that information will be given in the EOB. This makes easy for the billing team.  I found a good article on how to send the claims to the secondary payer via Paper CMS 1500 FORM. I am just giving that information here.

When the secondary is submitted on paper, the claim is printed out again on a cms form and a photocopy of the eob is attached. If other patients are listed on the eob, their personal information should be hidden. Many offices use black markers to draw through the unwanted information. Secondary is submitted on paper to the insurance companies that are not yet accepting electronic submissions.

New billing staff should understand that the secondary insurance plan cannot process the claim without a copy of the primary carrier EOB.

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 again on a CMS form and copies of the eobs of both the primary and the secondary insurance carriers are attached.

Whenever you send secondary and tertiary claims on paper, make sure the photocopies you attach are clear, easy to read, and for the correct date of service. Many insurance carriers scan the EOBs, which lightens them a little. If the copy you submitted was already light, by the time the claim is processed it may be sent back to you as unreadable. It takes a lot more time to find the original EOB and resubmit a claim than it does to get it right the first time.

Secondary and tertiary claims can sometimes seem like a pain to get paid – especially because they can be for a very small amount of money. It is still important to file and track these claims to keep your receivables under control. It may not seem like a lot of money but it adds up. If you have a system for submitting them it really isn’t that bad

A few Points to remember on Secondary Insurance:

  1. Claims can be submitted to the secondary Insurance via Paper CMS 1500 form or EDI.
  2. If you are sending via Paper, then don't forget to attach the Photocopies of the Primary Insurance EOB.
  3. If you are sending via EDI, then you should include some additional details in the EDI. Please look at the EDI Loop 2320, Loop 2330A and Loop 2330B
  4. If primary EOB contains co-pay/Coinsurance/deductible, then some secondary insurance will cover those amounts.
  5. Some times Primary Insurance itself will forward the claim to the secondary Insurance if they have the information. This will be informed in the Primary EOB.
  6. In some practices, provider want to write of the secondary insurance balance after the Primary insurance is paid and if the balance is small. So Your Practice management software should have the option of Write off the line item during Posting.
  7. Your Practice Management software should have the option of “Auto Bill to Secondary”. So if this option is enabled, during posting, if the claim contains balance and patient has secondary insurance, then it should add the claim to secondary insurance queue via EDI or paper.
  8. Your practice Management software should the balance for each claim or by each line item and also it should show who is the responsibility i.e Primary, Secondary, etc..
  9. If your practice practice Management software does not have the option of Printing the claim in CMS 1500 form, then no need to worry, You can still send the claims via EDI to the clearing house and then clearing house will send via paper to the respect insurance company. For the implementation details, you can check the clearing house.

    That's all

    Questions or feedback are always welcome. You can email me at


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    PPI Claims Made Simple

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