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Secondary insurance billing

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Nancyo2:
We have patients that have primary and secondary insurance companies- we send EOB with claim to secondary however, the secondary insurance asks for medical records etc to determine medical necessity.  Is it true that the primary plans determine medical necessity AND determines the allowed fees?  The secondary insurance then pays a portion of the %. Also, we have a few primary insurance companies that don't put CPT codes on the Explanation of Benefits, only a general description IE instead of CPT 37722, it will state Surgery. The secondary insurance won't pay unless there is a CPT code. Very frustrating!

Michele:

--- Quote from: Nancyo2 on September 21, 2017, 12:13:26 PM --- Is it true that the primary plans determine medical necessity AND determines the allowed fees?  The secondary insurance then pays a portion of the %.

--- End quote ---

No.  Each plan will apply their own rules.  Some may say that since the primary determined medical necessity they do not need to, but that is not a rule.  The secondary insurance will process the claim based on their rules.  They don't all necessary pay a portion. 



--- Quote from: Nancyo2 on September 21, 2017, 12:13:26 PM ---Also, we have a few primary insurance companies that don't put CPT codes on the Explanation of Benefits, only a general description IE instead of CPT 37722, it will state Surgery. The secondary insurance won't pay unless there is a CPT code. Very frustrating!

--- End quote ---

That is not common.  Is it a small carrier?  The EOBs that go to patients will have that, but usually the provider copy has the CPT.  I would contact the carrier to see if they have any options.


PMRNC:
I'm actually having this battle with my OWN health insurance company Administrator (Pomco) IT is NOT common to not have the CPT codes and I've been fighting with my own insurance company for a while and even have a complaint in with the dept of labor because it's an ERISA plan. Our EOB's will have "medical services" or "surgery" or "laboratory services" rather than the darn CPT code. It's Extremely frustrating and in all my years of doing billing and working for insurance companies.. this is the ONLY carrier I've encountered this with. Ironic it's my own.


--- Quote ---the secondary insurance asks for medical records etc to determine medical necessity.

--- End quote ---
No, I don't think THIS is uncommon, I do ped's and we have some plans with different COB models so we have been asked for records from the secondary when the primary didn't require them.


--- Quote --- Is it true that the primary plans determine medical necessity AND determines the allowed fees?  The secondary insurance then pays a portion of the %

--- End quote ---

No, I would not say that is common, each carrier might have their own criteria for determining medical necessity but it's not the "normal" to have the secondary decide.. if the primary allows, most secondary's allow, it really depends on the service. I've seen primary carriers deny genetic counseling for example and the secondary want medical necessity. It depends on the plans allowance and what their benefit plan states. If you come across a lot of these I would say your mostly dealing with ERISA plans and in those cases you want to ask the patient for a copy of their summary plan benefit. With ERISA, the patient MUST be involved with all appeals. MOST group plans are ERISA unless they are church/govt plans.


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