Forum - Questions & Answers

Dec 29th, 2020 - sharris

Insurance Rejections For Medical Necessity - Can 2nd insurance be billed?

I have a difference of opinion going on with our claims department.

If a patients primary insurance rejects a claim for medical necessity BUT the procedure is covered under the patients secondary insurance we can bill the 2nd with EOMB?

They are telling us if the primary rejects for this reason we CANNOT bill the secondary. I could be wrong but I fully disagree.

Your opinion on this would be gratefully accepted. :)

Thank You

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Jan 4th, 2021 - HowieFromJersey 1 

Depends on the nature of the 'secondary' policy

If the 'secondary' is structured as a true supplement (e.g. Medigap) to the primary policy then a 'no', denial by the primary will drive the decision by the supplement to also deny coverage. If they are truly separate policies, then it depends on any contractual relation between them. If there is none, then each has to make its coverage decision(s) based on its own criteria. Retiree and labor union policies will (or should) have specific rules regarding coverage by more than one policy; the benefits manager should be brought into the process. In addition, an insurer, structured as a supplement (Tricare comes to mind) may even be structured to flip to primary status if the primary declines coverage. The take-away here is never take 'no' for a final answer. Howard S.

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