When a patient is covered by a primary payer plan and a different secondary payer plan?
Asked by: Florine Gulgowski | Last update: January 13, 2026Score: 4.5/5 (51 votes)
When a patient is covered by primary payer plan and a different secondary payer plan?
The insurance that pays first (primary payer) pays up to the limits of its coverage. The insurance that pays second (secondary payer) only pays if there are additional costs the first payer didn't cover. The secondary payer (which could be Medicare) might not pay all of the remaining uncovered costs.
What happens if a patient is covered by two different policies?
If you have a primary and secondary health insurance, your bill will not be given to both of them at the same time. Your primary insurance will typically be billed first unless there is a rule under your Coordination of Benefits provision that decides which insurance pays first.
When a patient has a primary and secondary insurance and both are to be billed for a specific claim?
When a patient has both primary and secondary insurance, the two plans will work together to make sure they're not paying more than 100% of the bill total. They do this through a “coordination of benefits” or COB. The COB uses various industry regulations to establish which insurance plan is primary and pays first.
When a patient has dual coverage, the primary insurance is?
Final answer:
The primary insurance plan for a patient with dual coverage is typically the one where they are the policyholder, with the dependent coverage acting as the secondary payer.
Understand Medicare Secondary Payer (MSP) - Chapter 31
Can a patient have both primary and secondary insurance coverage?
Most individuals only have one health insurance plan, known as “primary” insurance. However, some people also secure additional medical coverage or a “secondary” insurance plan. Having dual coverage is perfectly legal.
When a patient is covered by the same primary and secondary commercial health insurance plan?
When a patient is covered by the same primary and secondary commercial health insurance plan, 1) Submit just one CMS-1500 to the payer. 2) Mail the remittance advice to the payer. 3) Send the secondary CMS-1500, but not the primary claim.
How is primary and secondary insurance billed?
Primary insurance pays first for your medical bills. Secondary insurance pays after your primary insurance. Usually, secondary insurance pays some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances).
Can a doctor refuse to bill secondary insurance?
A: The answers to your questions depend on state law. Some states require physicians to bill all insurers a patient has, without charge, whereas others do not. If the physician has a contract with the secondary insurer, then, by contract, he or she most likely is obligated to submit the bill.
How does primary and secondary insurance work with prescriptions?
The pharmacy will first process your prescription through the primary plan. Once that is done, they will then process the prescription again, this time using the secondary coverage. Depending on which employer the secondary coverage is through, your copay could be as low as $0.
When a patient has two insurances and they must be coordinated to determine?
Coordination of benefits allows two insurance carriers to determine their fair share of the cost for covered services. Your out-of-pocket cost for services is limited to the amount, if any, that remains unpaid by the insurers.
What is the birthday rule?
The rule requires that the parent whose birthday comes first in the calendar year would cover the cost of delivering the new baby regardless of whether one parent has better health coverage for a newborn than the other.
When the same BCBS payer issues the primary and secondary or supplemental policies, submit?
Explanation: When the same payer issues the primary and secondary or supplemental policies, you should indeed submit just one CMS-1500 claim. This is because the primary and secondary or supplemental policies are associated with the same payer, so it is more efficient to submit a single claim for both.
What does Medicare cover if it is secondary?
Medicare Secondary Payer (MSP) means another insurer pays for healthcare services first, making that insurer the primary payer. The secondary payer covers some or all of the remaining costs that the primary payer leaves unpaid.
Who is the primary payer when a patient is also covered by a Cobra plan?
Generally, if you are enrolled in both COBRA and Medicare, Medicare will be the primary payer and COBRA coverage will pay second. The secondary payer might not pay all of the uncovered costs. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
When a patient is covered through Medicare and Medicaid which coverage is primary?
People who have both Medicare and full Medicaid coverage are “dually eligible.” Medicare pays first when you're a dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.
Will secondary pay if primary denies?
It depends on which insurance is considered “primary” and which is “secondary.” The insurance that pays first (primary payer) pays up to the limits of its coverage. The insurance that pays second (secondary payer) only pays if there are costs the primary insurance didn't cover.
On what grounds can a doctor refuse to treat a patient?
The patient is disruptive or otherwise difficult to handle; The doctor does not have a working relationship with the patient's healthcare insurance provider; The doctor's personal convictions, such as a doctor refusing to perform an abortion for religious reasons or refusing to prescribe narcotics for pain; and.
What happens if you have primary and secondary health insurance?
Your primary plan processes the insurance claim first and covers the bill up to its coverage limits. If your primary insurance is unable to cover the entire claim, your secondary insurance may cover all or a portion of the remaining costs.
What is the difference between primary payer and secondary payer?
The “primary payer” pays what it owes on your bills first and sends the remaining amount to the second or “secondary payer.” There may also be a third payer in some cases.
When a patient has a secondary insurance policy, it is billed after the primary policy has paid, true or false?
Final answer: A patient with a secondary insurance policy is billed after the primary insurance has made its payment, which is true as the secondary insurance covers the remaining cost. This collaboration between insurance policies helps reduce the patient's overall out-of-pocket expenses.
What is the coordination of benefits rule?
“Coordination of benefits” or “COB” means a provision establishing an order in which plans pay their claims, and permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total allowable expenses.
How does dual insurance work?
Double coverage often means you're paying for redundant coverage. first. The other plan can pick up the tab for anything not covered, but it won't pay anything toward the primary plan's deductible. If both plans have deductibles, you'll have to pay both before coverage kicks in.
What is the birthday rule for insurance spouse?
The rule states that the insurance plan of the parent whose birthday comes up first in a calendar year is responsible for paying for the child's birth. HIGHLAND PARK, Calif. (KABC) -- If you and your partner are starting a family, and both of you have different health insurance plans, beware.
Do you have to pay if Medicare denies a claim?
If Medicare denies payment: You're responsible for paying. However, since a claim was submitted, you can appeal to Medicare. If Medicare does pay: Your provider or supplier will refund any payments you made (not including your copayments or deductibles).