The Complete Guide to Billing Secondary Insurance Claims

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It’s another day at your private medical practice and you’re working on verifying patient insurance and submitting claims. Then, one patient comes across your desk who has not one, but two insurance plans.

So, what do you do? How do you bill secondary insurance claims?

Managing claims for patients with primary and secondary insurance sounds complex. But following a few essential best practices can make the process smooth and ensure your practice is getting reimbursed as much as possible.

Insurance verification guide

Primary vs. Secondary Insurance

The first step in billing secondary insurance claims is understanding the difference between primary insurance and secondary insurance. Let’s dive into these two types of plans, what they cover and how to tell them apart.

What Is Secondary Insurance?

Secondary insurance is exactly as it sounds: it’s an additional insurance plan a patient may have on top of their primary insurance. When a provider files a claim for a patient’s care or service, the primary insurance pays that claim first. Once the primary payer covers its portion of the claim, secondary insurance pays a portion.

Oftentimes a patient has a second plan because they are employed but also have a government plan like Medicare, Medicaid or TRICARE. Sometimes the second plan is from a spouse or a parent with insurance.

What’s the Difference Between Primary vs. Secondary Insurance?

The main difference between primary and secondary insurance is that the primary insurance pays towards the claim first. The secondary insurance pays some or all of the remaining balance, which can often include a copay.

It’s important to note that having two insurance plans doesn’t mean the patient has zero payment responsibility. The secondary insurance won’t cover the primary insurance’s deductible, for example. Patients may also still be responsible for copays or coinsurance even after both insurance plans pay their portion of the claim.

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Scenarios Where Patients May Have Two Insurance Plans

The number of patients you see with secondary insurance often depends on the type of practice or medical specialty. Here are some scenarios where a patient may have secondary insurance:

• A patient over the age of 65 who has Medicare but is still working at a company with 20+ employees, so they have an insurance plan through their employer, too. Primary insurance = employer’s plan.
• A patient over the age of 65 who has Medicare and has a supplemental insurance plan. Primary insurance = Medicare.
• A patient who has insurance through their employer but also has insurance through their spouse’s employer. Primary insurance = the the patient’s employee plan.
• A patient who is age 26 or younger who is still covered under their parents’ insurance, but also has insurance through their employer. Primary insurance = the employer’s plan.
• A child who is covered under each parent’s insurance plan. Primary insurance = the parent with the earlier birthday in the calendar year.
• A patient who is receiving worker’s compensation and has an insurance plan. Primary plan = worker’s comp (for services related to the worker’s compensation injury).
• A patient who is receiving Medicaid but has another, private insurance plan. Primary plan = private plan.
• A member of the military who is covered under TRICARE but who also has a private insurance plan. Primary plan = private plan.

If you’re looking for more Medicare-specific information, check out this chart with examples of primary and secondary insurance .

How Do I Know Which Insurance Is Secondary?

When a patient has both primary and secondary insurance, the two plans will work together to make sure they’re not paying more than 100% of the bill total. They do this through a “coordination of benefits” or COB . The COB uses various industry regulations to establish which insurance plan is primary and pays first.

Determining which insurance is primary and which is secondary isn’t always straightforward. It often depends on the type of insurances the patient has and their age. It can also vary based on the size of the company that provides the employee insurance plan.

Generally, if a patient has insurance through their employer, that employer’s plan is their primary insurance. And if one of the patient’s plans is Medicaid, that’s almost always the secondary insurance. But exceptions can happen, so when in doubt, ask the patient to confirm the COB or call the insurance companies to double-check.

When Can You Bill Secondary Insurance Claims?

You can submit a claim to secondary insurance once you’ve billed the primary insurance and received payment (remittance).

It’s important to remember you can’t bill both primary and secondary insurance at the same time. Like many aspects of insurance billing and coding , insurance companies have strict specifications on what they will or won’t cover. They also have steps in place to make sure that both plans don’t pay more than 100% of the bill.

With that in mind, the secondary insurance company will need to see the bill total, how much the primary insurance paid and why they didn’t pay the remainder of the balance. Including the adjustments and categories for the remaining balance is crucial to a seamless secondary claim process.