Primary and Secondary Insurances

As a mental health clinician accepting insurance payments from your patients, you may come across some clients who have two insurances. You will need to work with your patient to identify which insurance is primary, and which insurance is secondary in order for insurance claims to process properly for that patient. The better the information that you have, the more likely you are to be paid for those sessions in a timely manner!

What’s the difference between Primary and Secondary Insurances?

The primary insurance policy is the policy that claims will be billed to first. The claim will process according to the patient’s insurance plan with the primary insurance and payments will be paid according to their benefits. Then, the claim will be sent on to the secondary insurance company. If the patient’s benefits with the secondary insurance company allow, additional payment may be made by the secondary insurance company.

Whether or not the secondary insurance will pay on a claim can vary from insurance company to insurance company, as well as from insurance plan to insurance plan. Performing an eligibility check for your patient with each insurance company is the best practice in understanding how claims will pay for your patients.

How to Know Which Insurance is Primary and Which is Secondary

The primary insurance plan should be designated by something called a Coordination of Benefits. Using a coordination of benefits form, a patient or a patient’s guardian can designate which insurance they would like as their primary and secondary insurance. If your patient has multiple insurance plans, ask them if they know which one is primary and which is secondary. If your patient is unable to tell you, you should be able to find out by calling each insurance company to verify.

In cases involving minors and young adults who are covered under their parent’s insurance plans, there is something called the birthday rule that determines which plan is primary and which plan is secondary.

The Birthday Rule

When a child is covered under both parents' health plans, the parent whose birthday falls first in the year (month and day only) is the primary insurance. The other parents' insurance provides secondary coverage.

Example: Patient's mother's birthday is October 11, and patient's father's birthday is April 24. In this case, the father's insurance would be the primary insurance and the mother's insurance would be the secondary.

If the parents share a birthday, the primary plan would be the plan which has been effective longer.

Example: Mom and Dad were both born on May 3, however Mom's plan has been active since 2013, and Dad's plan has been effective since 2019. In this case, Mom's plan would be primary and Dad's plan would be secondary.

If parents are divorced, there may be a court order to determine which insurance plan is primary. If there is no court order, the birthday rule would apply as in the first example.

If one parent is covered under COBRA, the other insurance plan will always be primary.

If a young adult (under the age of 26) is married and covered by both a parent and a spouse, the plan that has been effective longer will be primary. If the plans started the same day, the birthday rule will apply. However, if the young adult is covered on their health plan through their employer, that coverage would be primary and their parent/spouses' coverage would be secondary.

How Many Insurance Plans Can one Patient Have?

Having a secondary insurance plan is not uncommon, especially in the case of children who are covered by both parent’s insurance plans, as well as for elderly patients who have supplemental plans to Medicare and Medicaid. Less common is a tertiary (third) or quaternary (fourth) insurance plan. If you do encounter patients who have more than two plans, the process for claim submission is the same as with secondary plans.

Ensure that you have the proper coordination of benefits information from your patient. Perform Eligibility and Benefit checks with each insurance company. Check that your EHR has a place for you to input each of the insurance plans, and make sure that they are labeled according to which plan should receive the plan first, second, third, and fourth. The claim can then be submitted as usual!

Coordination of Benefits Issues

If you are having issues with claims not processing due to coordination of benefits, the solution lies in communicating with your patient to make sure that you have accurate information and confirming information with the insurance companies. This can be time consuming to resolve, but not impossible.

If you are struggling with resolving coordination of benefit issues and would like help in getting claims paid, Practice Solutions billers are here to help! Contact us today to learn more about our billing services.