Secondary Insurance and Medicare

It is fascinating to me how rapidly and completely something can move from primary to secondary. I started writing this blog post one and a half weeks ago. After all sorts of interruptions, it has finally made it back to primary position in my task queue. Since I have no formal rules for how a task becomes primary or secondary, it can sometimes be a challenge to prioritize.

An active discussion on our SOS User Group site on Medicare Crossover claim filing started me thinking about this matter of primary and secondary insurance. Somehow, in our day-to-day lives, we have complete understanding of what these words mean, even if we have no formal definitions. When it comes to insurance, everything changes; the meanings and functions of primary and secondary become murky. Because we have addressed this issue here in this blog and in a couple of documents on our web site, internet searches for ‘filing secondary insurance’ often hit upon the article that Manon wrote on the subject or on the blog post. I am surprised at how frequently those searches and hits happen.

Our User Group discussion (just scroll to the top for the start of the thread) talked about the requirements placed upon Medicare Participating Providers to file secondary or crossover claims for their patients. Most of the participants indicated their understanding that it is necessary for Participating Providers to do this. Some discussants indicated that crossover claims are sent to the secondary insurer automatically. A couple of others indicated that there is some special process that they must go through to make this happen.

I know that one of the most important improvements in the 5010 version of the 837 claims transaction is requirement for the inclusion of more specific Coordination of Benefit information in the claim. Manon attended a Medicare webinar this week that discussed progress on meeting the 5010 requirements. Apparently, crossovers have been a big issue in this 5010 transition, but CMS indicates that they have made significant advance in working out the issues about crossovers.

Medicare regulations detail requirements for Coordination of Benefit Agreements and Coordination of Benefit Contractors. Unfortunately, wading through 124 pages of regulations to completely understand this process seems like overkill for an individual provider. Add to that the fact that different Medicare Administrative Contractors (MACs) may have different procedures, different Coordination of Benefit Contractors, and be in different stages of implementation of this process. In fact, a Google search for Medicare Crossovers comes up with documents created by many of the different MACs.

Getting your MAC to tell you what must be in your claims, what you as a provider are required to do for your patient, and what your patient may be required to do to complete the filing of secondary (crossover) claims seems like the reasonable course of action. I would be amazed if there is not detailed information on your MAC’s website.

Let us know if you are able to find out useful information. We can post the links here to make it easier for others to find what they need about the topic of Medicare Crossovers. Please share your comments below.

0 thoughts on “Secondary Insurance and Medicare

  • Have you heard of NAIC numbers. When we go to file a secondary claim and Medicare is primary, it asks for the NAIC number for Medicare. BCBS has no idea and the person we spoke to at Medicare was no help either.

  • Rita, are you sure it was “NAIC”? One of the translations for that acronym is “National Association of Insurance Commissioners” which publishes guidlines for coordination of benefits. That seems relevant, but I did not find any indication that they issue numbers to be used in the process.

    “NEIC” (as opposed to “NAIC”) was the first of the big medical claim clearinghouse vendors, and did issue payer identifiers. That company has been absorbed by Emdeon/WebMD and I guess the current emdeon payer numbers may well be derived from the original NEIC list.

    There is a value called an “ICN” (stands for Internal Control Number) that allows precise tracking back to the claim identifier assigned to a specific claim by the primary insurer during processing. We have gotten feedback from some customers of rejections by some secondaries because the primary ICN was not included in the secondary electronic claim submission. SOS is about to release an update that supports inclusion of this ICN number for secondaries.

    • Thanks to Rita, Seth and Bart for comments. Rita also brought this discussion to our user group and Julie Kopacek shared that NAIC stands for National Association of Insurance Commissioners. The number used for all Medicare payers seems to be 9999999.

      “I googled medicare NAIC number and it took me to http://www.phc4.org which has most common NAIC numbers medicare is listed on appendix C as 9999999 use only for fee for service Medicare not managed care.
      Julie”

      This is pretty strange as most Blues participate as Medigap payers with Medicare, so the secondary should be crossed over automatically as long as the payer’s Medigap number is properly entered in the claim. Our software certainly handles that…as I am sure most do…but the Medigap number must be entered in the correct place by the User.

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