Claims FAQ

Why Don’t My Secondary Claims Crossover?

The terms “MSP” and “COB” are found in heavy use these days, but getting the claims paid seems more difficult than ever. Many payers no longer accept secondary claims on paper, some can’t receive electronic claims yet, and all struggle with updating their systems to be compliant with current HIPAA legislation.

The main question is this: if my EOB from the primary payer states “Claim information forwarded to …” why don’t I get paid?

For the most part it is a matter of provider identification. If the primary payer receives NPI only to identify you, that’s all they can forward on to the secondary payer. If the secondary payer needs a PIN number to identify you, the claim may reach them but they don’t know who to pay.

Another problem that affects the payment process is standard codes for adjustments and denial reasons. Many times the primary payer’s EOB contains proprietary codes to explain the payment details, and the other payer needs standard codes.

The third item of concern is the most difficult for most providers to solve. In the past, secondary claims were filed by printing a copy of the primary claim, attaching a copy of the primary payment EOB and mailing them to the secondary payer. Claims were paid on a claim-level basis, which means one total for the entire claim, regardless of the number of services billed. Now the data describing the insured has to appear in opposite areas of the claim for the destination payer than it does for the other payer. Furthermore, all details regarding payment have to be broken down on a line-level basis, which is service by service.

In order to meet the current requirements, all secondary claims must include:

• payment date
• payment amount
• allowed amount
• adjustment reason
• adjustment group
• adjustment amounts for up to four adjustments per line of service.

Also included are:

• total paid amount
• total allowed or approved amount
• payment date

If your practice management system cannot store these details on a line-level basis, it will be difficult to file successful secondary claims that get paid with a minimum of fuss.

SolAce EMC Products have been used to successfully file secondary and MP claims since early 2005. The process of creating a patient record and preparing a secondary claim is extremely easy and can be done in just 2 or 3 minutes.

For more information on training for secondary claims, please mail webdemo@solace-emc.com.