Claim Forward to Other Payer

Let me explain Life Cycle of a Claim with an example

Patient Name: John
John covered by Employer with the Insurance Aetna and he also having personal insurance Healthnet.
In this case, Aetna becomes primary and Healthnet Insurance becomes secondary.
The Life cycle of the claim

1. Billing Team sends the claim to primary Insurance Aetna for the Billed Amount of $100.
   Date of Submission Primary Insurance: 12th March 2019
2. Aetna processes the claim and generates the EOB with EDI 835 for payment of $80 and $20 as coinsurance.
   Please note, most claims are processed within 60 days by all payers.
   Date of Processing the claim and EOB generation: 1st April 2019
3. Please remember, in some cases, EOB reaches first and then later funds are transferred to the service provider bank account.
4. Once the Billing team gets the EOB or ERA, they will post the payments into the system.
   Date of Payment Posting: 5th April 2019.
5. Now the billing team identifies that there is still $20 balance in the claim and patient has secondary insurance and now they want to send the same
   claim to the secondary insurance for the remaining balance.
6. So the billing team either uses the Paper claim option or EDI option to send the claim to secondary insurance.
   Date of Submission Secondary Insurance: 7th April 2019
7. Healthnet Insurance process the claim and generates the EOB with EDI 835 for payment of $20
   Date of Processing the claim and EOB generation: 20th April 2019
8. The billing team receives the EOB or ERA from Healthnet insurance and post the payments.
   Date of Payment Posting: 22 April 2019.

Now you will get an idea of how the claim reaches the final state in the claim Life cycle starting from 12th March 2019 to 22 April 2019.In the above workflow, steps 5 and 6 can be avoidable and save the Billing teamwork and speed up the collection if we do the below process.

1. X12 EDI 837 has the option of sending the additional Payer information. Loop#2320 -Other Subscriber Information. So ask your IT team to include that information in the Primary EDI. Most of the developers will ignore this because they only focus on mandatory items in the EDI.
2. Now after Aetna process the claim, their system identifies the claim has still balance and EDI 837 contains secondary insurance information. So they will forward your claim to Secondary Insurance Healthnet with their payment information. They will also notify this forward information in the EOB Please check the EOB at the bottom for example.
3. So now your billing team does not worry about sending the claims to secondary either paper or EDI