When we first started our medical billing business in 1994 I had no previous experience at billing any medical claims, let alone secondary and tertiary. (You mean some people have 3 insurances?) I knew nothing. In fourteen years of billing I’ve learned quite a bit and I see from questions in our forum that many beginners do not understand secondary and tertiary claims billing at all.
First of all, how does anyone get two or three policies and which is determined primary? If a husband and a wife both work (who doesn’t?) and they are both covered by health insurance by their employers, they may both have family policies so they are both covered under each others plan. One would be primary and the other secondary. Now if one of this couple (a few years ago we would have assumed that it would only be the husband) had previous military experience and carried over their Tricare military insurance, that would be the third payor (if there was a balance left).
Which company is primary and which one is secondary is determined by one of a couple different methods. First of all, if a person is working and they carry insurance, that insurance is primary (unless they have Medicare and their employer has less than 100 employees). If a person is retired and has Medicare but the spouse works and carries a family policy, then the spouse’s plan would be primary and the Medicare would be secondary.
There is no way to cover every scenario but basically whether or not the person or the spouse is working can determine the order. For dependants (usually children) some go by the “birthday rule” meaning that whichever parents birthday falls first in the year is primary. Of course with all of the divorce out there sometimes the order of insurance is determined by a court order.
When a patient is seen by a provider the claim is sent on a CMS 1500 form to the primary insurance carrier either electronically or on paper. Electronically it can be sent either directly to the insurance carrier by special software or through a service or through a clearing house. When sent on paper it simple means the claim is printed to a paper CMS 1500 form and sent through the mail. Whatever the case is, it is important that you know the order of the policies.
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.
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 (we call them smelly pens) to draw through the unwanted information. I’ve set up a bunch of various width strips of white cardboard that we slide into clear report covers to cover the unwanted information before we photocopy. We only do this with companies that are not yet 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 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.