Primary Claims Submission Includes A Patient Who Has Coverage By

Navigating the complexities of primary claims submission, especially when a patient has multiple insurance coverages, can be a daunting task for healthcare providers and billing professionals. Understanding the intricacies of coordination of benefits (COB), primary versus secondary insurance, and the specific rules governing claim submissions is crucial for ensuring accurate and timely reimbursement. This comprehensive guide will delve into the world of primary claims submission for patients with coverage from multiple sources, providing clarity on the process and best practices for efficient claims management.

Understanding Primary and Secondary Insurance

At the heart of primary claims submission lies the concept of coordination of benefits (COB). COB is the process by which insurance companies determine which plan is responsible for paying first when a patient has coverage under more than one health insurance plan. The primary insurance is the plan that has the first responsibility for paying claims, while the secondary insurance pays after the primary insurance has processed the claim.

Determining which insurance is primary and which is secondary is governed by a set of rules, often dictated by the National Association of Insurance Commissioners (NAIC) and specific state regulations. These rules generally consider factors such as:

• Employee vs. Dependent Coverage: If a patient has coverage under their own employer-sponsored plan and as a dependent on a spouse's or parent's plan, their own employer-sponsored plan is typically primary.
• Birthday Rule: For dependent children covered by both parents' plans, the plan of the parent whose birthday falls earlier in the calendar year is usually primary. This rule applies regardless of which parent is older.
• Custody Arrangements: In cases of divorce or separation, the court order often dictates which parent's plan is primary. If the court order doesn't specify, the birthday rule may apply.
• Medicare and Employer Group Health Plans: If a patient is eligible for Medicare and also covered by an employer group health plan, the employer plan is usually primary if the employer has 20 or more employees. If the employer has fewer than 20 employees, Medicare is primary.
• COBRA Coverage: If a patient is covered by COBRA (Consolidated Omnibus Budget Reconciliation Act) and another health plan, the COBRA plan is usually secondary.

Gathering Patient Information and Verifying Coverage

Before submitting a primary claim, it's essential to gather comprehensive patient information and verify coverage details. This includes:

1. Patient Demographics: Collect accurate patient information, including name, date of birth, address, phone number, and social security number or patient identification number.
2. Insurance Cards: Obtain copies of all insurance cards, both primary and secondary. This will provide essential information such as the insurance company's name, address, phone number, member ID, group number, and claim submission instructions.
3. Coordination of Benefits Form: Ask the patient to complete a coordination of benefits (COB) form. This form gathers information about all other insurance coverage the patient has, helping to determine which plan is primary.
4. Coverage Verification: Verify the patient's coverage with both the primary and secondary insurance plans. This can be done online through the insurance company's website or by calling the provider services department. Confirm the patient's eligibility, coverage dates, benefits, and any applicable co-pays, deductibles, or co-insurance amounts.
5. Prior Authorization Requirements: Determine if any services require prior authorization from the primary insurance plan. Failure to obtain prior authorization when required can result in claim denial.

Preparing the Primary Claim

Once you have gathered the necessary patient information and verified coverage, you can begin preparing the primary claim. This involves:

1. Selecting the Correct Claim Form: Use the appropriate claim form for the service provided. The CMS-1500 form is commonly used for physician and outpatient services, while the UB-04 form is used for inpatient hospital services.
2. Accurate Coding: Use accurate and up-to-date ICD-10 (International Classification of Diseases, 10th Revision) codes to diagnose the patient's condition and CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes to describe the services provided.
3. Modifiers: Apply appropriate modifiers to the CPT or HCPCS codes to provide additional information about the service, such as whether it was performed bilaterally or with special circumstances.
4. Units of Service: Indicate the number of units of service provided.
5. Charges: List the charges for each service provided.
6. Rendering Provider Information: Include the rendering provider's name, National Provider Identifier (NPI), and address.
7. Billing Provider Information: Include the billing provider's name, NPI, and address.
8. Place of Service: Indicate the location where the service was provided, such as an office, hospital, or nursing home.
9. Patient's Signature: Obtain the patient's signature or authorization to release medical information to the insurance company.
10. Coordination of Benefits Information: Indicate that the patient has other insurance coverage and provide the primary insurance information, including the insurance company's name, address, member ID, and group number.

Submitting the Primary Claim

After preparing the primary claim, you can submit it to the primary insurance plan. This can be done electronically or by mail, depending on the insurance company's requirements.

1. Electronic Claim Submission: Electronic claim submission is the preferred method for most providers as it is faster, more efficient, and reduces the risk of errors. You will need to use a clearinghouse or billing software that is compatible with the insurance company's electronic claim submission requirements.
2. Paper Claim Submission: If you are submitting a paper claim, make sure to use the correct claim form and follow the insurance company's instructions for completing and submitting the form.
3. Supporting Documentation: Include any necessary supporting documentation with the claim, such as medical records, operative reports, or prior authorization approvals.
4. Claim Tracking: Keep a record of all submitted claims and track their status. This will help you identify and resolve any issues that may arise.

Processing the Primary Insurance Payment

Once the primary insurance plan processes the claim, they will send an Explanation of Benefits (EOB) to both the patient and the provider. The EOB will detail the services that were covered, the amount that was paid, any patient responsibility (such as co-pays, deductibles, or co-insurance), and any reasons for denial.

1. Review the EOB: Carefully review the EOB to ensure that the claim was processed correctly and that the payment is accurate.
2. Post the Payment: Post the payment to the patient's account in your billing system.
3. Adjust the Patient Balance: Adjust the patient's balance to reflect any co-pays, deductibles, or co-insurance amounts that are the patient's responsibility.
4. Secondary Claim Submission: If the patient has secondary insurance, you will need to submit a claim to the secondary insurance plan.

Submitting the Secondary Claim

After the primary insurance has processed the claim and you have received the EOB, you can submit a claim to the secondary insurance plan.

1. Obtain the Primary Insurance EOB: You will need to include a copy of the primary insurance EOB with the secondary claim. This will provide the secondary insurance plan with information about how the primary insurance processed the claim.
2. Complete the Secondary Claim Form: Complete the secondary claim form, indicating that the patient has primary insurance coverage and providing the primary insurance information.
3. Submit the Secondary Claim: Submit the secondary claim to the secondary insurance plan, either electronically or by mail, depending on the insurance company's requirements.

Processing the Secondary Insurance Payment

Once the secondary insurance plan processes the claim, they will send an EOB to both the patient and the provider. The EOB will detail the services that were covered, the amount that was paid, and any patient responsibility.

1. Review the EOB: Carefully review the EOB to ensure that the claim was processed correctly and that the payment is accurate.
2. Post the Payment: Post the payment to the patient's account in your billing system.
3. Adjust the Patient Balance: Adjust the patient's balance to reflect any remaining patient responsibility. In some cases, the secondary insurance may cover all or part of the patient's remaining responsibility.

Common Challenges and How to Overcome Them

Submitting primary claims when a patient has multiple insurance coverages can present several challenges. Here are some common issues and how to address them:

• Incorrect Primary Insurance Information: If the primary insurance information on file is incorrect, the claim may be denied. To prevent this, always verify the patient's insurance coverage and coordination of benefits information at each visit.
• Lack of Coordination of Benefits Information: If the patient does not provide complete coordination of benefits information, it can be difficult to determine which plan is primary. Make sure to ask patients to complete a coordination of benefits form at each visit and update their information as needed.
• Prior Authorization Issues: Failure to obtain prior authorization when required can result in claim denial. Check the primary insurance plan's requirements for prior authorization before providing any services that may require it.
• Claim Denials: Claims may be denied for a variety of reasons, such as incorrect coding, lack of medical necessity, or failure to meet the insurance plan's coverage criteria. Carefully review the EOB to understand the reason for the denial and take appropriate action, such as correcting and resubmitting the claim or appealing the denial.
• Timely Filing Deadlines: Insurance plans have timely filing deadlines for submitting claims. Failure to submit a claim within the timely filing deadline can result in denial. Be sure to submit claims promptly to avoid missing these deadlines.

Best Practices for Efficient Claims Management

To ensure efficient claims management when a patient has multiple insurance coverages, consider implementing the following best practices:

• Train Staff: Provide thorough training to billing staff on coordination of benefits rules, primary and secondary claim submission procedures, and common challenges.
• Implement a System for Tracking Claims: Use a billing system or spreadsheet to track the status of all claims and identify any issues that need to be resolved.
• Verify Insurance Coverage Regularly: Verify patients' insurance coverage and coordination of benefits information at each visit.
• Stay Up-to-Date on Insurance Regulations: Keep abreast of changes in insurance regulations and coding guidelines.
• Communicate with Insurance Companies: Establish relationships with insurance company representatives and don't hesitate to contact them with questions or concerns.
• Utilize Technology: Leverage technology to automate claims processing and improve efficiency.
• Regular Audits: Conduct regular internal audits of claims submission processes to identify and correct any errors or inefficiencies.

The Impact of Technology on Primary Claims Submission

Technology plays a crucial role in streamlining and optimizing primary claims submission processes. Electronic Health Records (EHRs) and Practice Management Systems (PMS) are integrated platforms that facilitate the seamless flow of patient information, coding, and billing data. These systems offer features such as:

• Automated Eligibility Verification: Real-time verification of patient insurance coverage and benefits.
• Coding Assistance: Built-in coding tools to ensure accurate and compliant coding.
• Electronic Claim Submission: Secure and efficient electronic submission of claims to insurance companies.
• Claim Tracking and Management: Comprehensive tracking of claim status and automated alerts for denials or rejections.
• Reporting and Analytics: Robust reporting capabilities to monitor claims performance and identify areas for improvement.

Clearinghouses act as intermediaries between healthcare providers and insurance companies, further simplifying the claims submission process. They perform edits and validations on claims before submitting them to payers, reducing the likelihood of errors and denials.

Future Trends in Primary Claims Submission

The landscape of primary claims submission is constantly evolving, driven by technological advancements, regulatory changes, and the increasing complexity of healthcare financing. Some future trends to watch include:

• Artificial Intelligence (AI) and Machine Learning (ML): AI and ML are being used to automate various aspects of claims processing, such as coding, claim scrubbing, and fraud detection.
• Blockchain Technology: Blockchain has the potential to improve the security and transparency of claims transactions.
• Value-Based Care: The shift towards value-based care models is driving the need for more sophisticated data analytics and reporting capabilities to track and measure outcomes.
• Increased Focus on Patient Engagement: Patients are becoming more involved in their healthcare decisions and are demanding greater transparency in billing and claims processes.

Conclusion

Mastering primary claims submission when a patient has multiple insurance coverages requires a thorough understanding of coordination of benefits rules, accurate coding practices, and efficient claims management processes. By following the guidelines and best practices outlined in this article, healthcare providers and billing professionals can navigate the complexities of primary claims submission with confidence, ensuring accurate and timely reimbursement for services rendered. Staying informed about the latest technology and trends in claims processing will be essential for continued success in the ever-changing healthcare landscape.