Secondary Insurance
Patients can have unlimited insurance plans. The
Insurance Plan
listed second (Order 2) in the Family Module is considered secondary insurance, though can be changed by modifying the Order Number.
Most insurances follow the "Birthday Rule." This means if a dependent is covered by two parents or guardians, the parent or guardian whose birthdate falls first in a calendar year will be the one providing primary coverage.
Creating Secondary Claims
Secondary claims are automatically generated when a primary claim is created by clicking New Claim in the Account Module. The primary claim will have "Waiting to Send" status and the secondary will have "Hold until Pri received" status.
A secondary claim may need to be completed manually if the secondary Insurance Plan was added after creating the primary claim. To do this, highlight the procedures in the Account Module, then click the New Claim dropdown menu and select Secondary.
When primary and secondary claims are created, they'll display in the Account Module similar to the following image.
Sending Secondary Claims
When you enter payment for the primary claim, you'll get one of two popups depending on whether the "Prompt for secondary claims" box is checked in Account Module Preferences.
Send Outstanding Secondary Claims Prompt
If the "Prompt for secondary claims" box is checked, you'll receive a popup with three choices and you'll simply choose according to your office workflow:
- Change the claim status to "Waiting to Send"
- Send secondary claim(s) now
- Do nothing
Outstanding Secondary Claims Notice
If the box is unchecked, you will not have the option to make changes to the status or send the claim. Instead, you'll get a popup that says "Some of the payments have secondary claims" along with a list that includes the date of service, patient number, and patient name for each claim processed that has a secondary claim.
Press "Copy All" to copy the list for pasting into a word processing document for reference or press "Print" to print a copy. Then, click "OK" to dismiss the popup.
From there, you'll need to manually find and open the secondary claim, verify the estimates, and send it.
Electronic Claims
If your clearinghouse accepts attachments, you can send electronic secondary claims with a copy of the primary EOB and any additional required documentation. Some clearinghouses require you to upload the attachment to the clearinghouse first. Others only require claim attachments to be marked electronic when sent. You will be notified when the attachment is required.
You will need to send electronic claims in the 5010 format for the clearinghouse to receive primary claim information. The 4010 format does not transmit it.
Procedures Marked as Do Not Bill to Insurance
A procedure marked as "Do Not Bill to Ins" can be changed on an insurance estimate.
To do so, double-click the claim and either add or remove the checkmark next to "Do Not Bill to This Insurance."
In the estimates section, procedures that will be sent in a claim appear without an "x" in the NoBill column, while procedures that will not be sent appear with an "x" in the NoBill column.
Note that if a procedure is marked as NoBill and it is selected when creating a claim, you will receive a popup saying "The following procedures were marked as NoBillIns..." with a list of applicable procedures.
Estimates
Secondary estimates do not automatically update if the primary insurance is received and not paid as estimated.
For greater accuracy with estimates, both primary and secondary Insurance Plan must be set up with the Plan Type of PPO Percentage.
Coordination of Benefits
Coordination of Benefits (COB) rules determine how a plan pays when a patient has more than one plan. These rules are set in the Edit Insurance Plan window and there are four options to choose from: Basic, Standard, CarveOut, and SecondaryMedicaid.
Basic
With the Basic COB Rule, the secondary insurance pays the lesser of the amount it would have if there was no other coverage or the secondary allowed amount minus the primary payment.
Standard
With the Standard COB Rule, the secondary insurance pays the lesser of the amount it would have if there was no other coverage or the patient's portion under the primary plan.
Carve Out
The Carve Out Rule is sometimes referred to as the non-duplication Rule. The secondary considers what it would have paid if it was primary and then subtracts what the actual primary paid.
Secondary Medicaid
When Medicaid is secondary, it reduces what it would have paid as primary by the amount the primary paid. The patient portion then becomes a secondary insurance write-off. Note: most secondary insurances outside this example do not have write-offs. Typically, only primary insurances have write-offs.
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