When we first started our medical billing enterprise in 1994 I had no previous sense at billing any medical claims, let alone secondary and tertiary. (You mean some habitancy 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 considered primary? If a husband and a wife both work (who doesn't?) and they are both covered by condition guarnatee 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 merge (a few years ago we would have assumed that it would only be the husband) had previous troops sense and carried over their Tricare troops insurance, that would be the third payor (if there was a equilibrium left).
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Which enterprise is primary and which one is secondary is considered by one of a merge separate methods. First of all, if a person is working and they carry insurance, that guarnatee is primary (unless they have Medicare and their manager 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.
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There is no way to cover every scenario but basically whether or not the person or the spouse is working can conclude the order. For dependents (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 separation out there sometimes the order of guarnatee is considered by a court order.
When a patient is seen by a victualer the claim is sent on a Cms 1500 form to the primary guarnatee carrier whether electronically or on paper. Electronically it can be sent whether directly to the guarnatee carrier by special software or through a aid 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. anyone the case is, it is leading that you know the order of the policies.
Once the primary guarnatee carrier pays their share of the claim it is then submitted to the secondary guarnatee enterprise 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 data from the eob (explanation of benefits) is entered into the claim data and submitted to the secondary guarnatee 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 data 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 discrete width strips of white cardboard that we slide into clear article covers to cover the unwanted data before we photocopy. We only do this with associates that are not yet accepting electronic submissions.
If there is still a equilibrium after the secondary guarnatee 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 guarnatee 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 strict date of service. Many guarnatee 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 primary 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 whole of money. It is still leading 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 theory for submitting them it verily isn't that bad.
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