If you have Medicare and other health insurance or coverage, each type of coverage is called a "payer." When there is more than one payer, "coordination of benefits" rules decide which one pays first. The "primary payer" pays what it owes on your bills first, and then sends the rest to the "secondary payer" to pay. The insurance that pays first is called the primary payer. The primary payer pays up to the limits of its coverage. The insurance that pays second is called the secondary payer. The secondary payer only pays if there are costs the primary insurer didn't cover.
The Medicare Coordination of Benefits (COB) program wants to make sure Medicare pays your claims right the first time, every time. The Benefits Coordination & Recovery Center (BCRC) collects information on your health care coverage and stores it in your Medicare record. This record must be updated every time you make a change to your health care coverage. Information comes from these sources:
- Your Medicare Secondary Claim Development Questionnaire,
- Your doctor and other providers,
- Your group health plan,
- Your employer, and
- You.
Medicare may be your secondary payer. Your record should show whether a group health plan or other insurer should pay before Medicare. Paying claims right the first time prevents mistakes and problems with your health care plans. To ensure correct payment of your Medicare claims, you should:
- Respond to Medicare Secondary Claim Development Questionnaire letters in a timely manner.
- Tell the BCRC about any changes in your health insurance due to you, your spouse, or a family member’s current employment or coverage changes. The BCRC’s information can be accessed by clicking Contacts in the Related Links section below.
- Tell your doctor and other health care providers if you have coverage in addition to Medicare.
- Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment.
For more information on how Medicare works with other insurance, click the medicare.gov link found in the Related Links section below. Next, go to the “Supplements and Other Insurance” menu option at the top of the page and select “How Medicare works with other insurance” from the drop-down list. Additional information can be accessed by selecting the Coordination of Benefits link also found in the Related Links section.
Medicare Secondary Claim Development Questionnaire
The Medicare Secondary Claim Development Questionnaire is sent to obtain information about other insurers that may pay before Medicare. When you return the questionnaire in a timely manner, you help ensure correct payment of your Medicare claims.
This questionnaire is mailed when a claim is submitted to Medicare with an explanation of benefits (EOB) attached, a self-report is made by you or your attorney identifying a Medicare Secondary Payer (MSP) situation, or an insurer submits MSP information to a contractor, or the BCRC. This questionnaire asks:
- If you have other health insurance or coverage based upon your current employment;
- If you are receiving black lung benefits, workers' compensation benefits, or treatment for an injury or illness for which another party could be held liable, or are covered under automobile no-fault insurance; and
- If you have other health insurance or coverage based upon a family member's current employment.
You may access a sample Medicare Secondary Claim Development questionnaire in the Downloads section at the bottom of this page. Note that the questionnaire you receive may appear slightly different depending on the reason you are entitled to Medicare. If assistance is needed in completing the questionnaire, the BCRC should be contacted. For BCRC contact information, please click the Contacts link in the Related Links section below.
FAQs
The insurance that pays first is called the primary payer. The primary payer pays up to the limits of its coverage. The insurance that pays second is called the secondary payer. The secondary payer only pays if there are costs the primary insurer didn't cover.
How do I argue with health insurance? ›
Steps to Appeal a Health Insurance Claim Denial
- Step 1: Find Out Why Your Claim Was Denied. ...
- Step 2: Call Your Insurance Provider. ...
- Step 3: Call Your Doctor's Office. ...
- Step 4: Collect the Right Paperwork. ...
- Step 5: Submit an Internal Appeal. ...
- Step 6: Wait For An Answer. ...
- Step 7: Submit an External Review. ...
- Review Your Plan Coverage.
How does secondary insurance work? Secondary insurance plans work along with your primary medical plan to help cover gaps in cost, services, or both. Supplemental health plans like vision, dental, and cancer insurance can provide coverage for care and services not typically covered under your medical plan.
Which insurance is primary when you have two? ›
Usually, your employer's plan is primary. If you also are covered by your spouse's plan, that plan is usually secondary. There are other rules for many other situations. A special case may come up if you have both medical and dental insurance, and you have a procedure such as oral surgery.
What happens if a patient has coverage under two insurance plans? ›
Having two health insurance policies doesn't mean you'll be covered twice by both plans. For example, if you sprain your ankle and go to the doctor, your visit isn't going to be reimbursed multiple times. Both plans may cover some of the expenses, but the combined benefits won't surpass the total cost of your visit.
Does it make sense to have two health insurance plans? ›
Multiple plans can offset more costs, increasing your savings when receiving healthcare. For example, your primary insurance might only cover 80% of a specific procedure. If your secondary insurance covers the rest, you bear no cost.
How often are health insurance appeals successful? ›
When consumers challenge a healthcare service their insurer denied, they win about half the time, data from California insurance departments show.
Which health insurance company denies the most claims? ›
UnitedHealthcare is the worst insurance company for paying claims with about one-third of claims denied. Kaiser Permanente is the best large health insurance company for paying claims, denying only 7% of medical bills.
How do you answer insurance questions? ›
Think deeply about the exact question the agent asked, and only provide that specific information. Never admit to fault. Never admit to even being partially at fault. Never admit that you are uninjured.
Is there a downside to having a secondary insurance? ›
Drawbacks of dual health insurance
Out-of-pocket costs: Having two health insurance plans, doesn't necessarily mean that you will be completely covered regarding your out-of-pocket expenses. Remember that the combined coverage of your plans cannot exceed 100 percent of your out-of-pocket costs.
In most cases their secondary policy will pick up the copay left from the primary insurance. There are some cases where the secondary policy also has a copay and those patients may end up with a copay applied after both insurances process the claim.
How does gap health insurance work? ›
A medical gap plan pays the amount applied to the insured's major medical deductible and coinsurance. It covers the same expenses as the major medical plan except for charges for professional fees in a doctor's office or medical clinic, outpatient prescription drugs, vision, dental, and plan copayments.
Which insurance to use as primary? ›
How do you determine which health insurance is primary? Determining which health plan is primary is straightforward: “If you are covered under an employer-based plan, that is primary,” Mordo says. If you also were covered under a spouse's plan, that would be secondary, he adds.
What happens if secondary insurance pays more than primary? ›
A credit balance results when the secondary payer allows and pays a higher amount than the primary insurance carrier. This credit balance is not actually an overpayment. The amount contractually adjusted off from the primary insurance carrier was more than needed, based on the secondary insurance carrier's payment.
What is dual coverage insurance? ›
Both plans won't fully cover each approved procedure. In a dual coverage scenario, the primary carrier (or primary plan) will pay a larger portion of the benefits, while the secondary carrier (or secondary plan) pays a smaller amount.
What determines which parents insurance is primary? ›
How does the birthday rule work? The birthday rule determines the order that the insurance companies will pay benefits when a dependent child is covered by two health insurance plans. The health insurance plan of the parent whose birthday month and day occurs earlier in the calendar year is primary.
Does it matter who the primary insured is? ›
It matters who the primary driver is on insurance because the primary driver is the person who drives the car the most. Insurance companies use their driving record, age, location, and other factors to calculate premiums and coverage. So the primary driver can affect insurance rates.
What makes an insurance policy primary? ›
What Does Primary Insurance Mean? Primary insurance is a policy that pays for coverage first, even when the policyholder has other policies that cover the same risk. Those other policies will only be tapped when the primary policy has reached its financial limit.
