Generate Secondary Claims
This document outlines when to generate a Secondary Claim and steps to generate the Secondary Claim.
When to generate a Secondary Claim
To generate a Secondary Claim, the following conditions should be satisfied.
- Patients should have active Secondary Insurance.
- Primary Claim payments should have Patient Responsibility (PR), or some procedures were not covered/paid by the Primary Payer.
Generating Secondary Claims
- Use the claim filter 'Primary/Secondary > Claims have PR with Patient Secondary Payer & No Secondary Claim' to see all the claims available for secondary insurance processing.
- Choose a Primary Claim, click on the 'Generate Secondary Claim (CMS1500)' option under the 'More options' (...) icon against the Primary Claim. If the Primary Claim is in 'Not Submitted' status, the Secondary Claim cannot be generated.
- Clicking on the 'Generate Secondary Claim' option opens up the Claim wizard. This pre-populates all the Claim information from the Primary Claim except the following such as, the Prior Authorization Number of the Primary Claim, Original Reference Number used if the Primary Claim is resubmitted, Secondary Insurance for the Patient is chosen as Primary Insurance for this Secondary Claim; Primary Insurance in the Primary Claim is chosen as Secondary Insurance in the Secondary Claim.
- Payment received from the Primary Payer should be entered in the 'Amount Paid (Copay)(29)' field.
- Go through the CMS1500 form claim wizard, verify the details, and save the claim.
When Practice is submitting Claims using Print Image File(PIF)
- Print the secondary Claim on CMS 1500 form.
- Print the Explanation of Benefits (EOB) document received from the Primary Payer.
- Send the Claim CMS form along with the Primary EOB to the Secondary Payer either by fax or by mail.
When Claims are submitted electronically (e-Claims package enabled Practices)
When electronic Claim submission is enabled for the Practice, the Secondary Claim along with the Primary EOB information can be sent electronically to the Secondary Payer. The Primary EOB information should be entered in the 'Adjudication Details' section, which is shown at the bottom of the CMS1500 Form claim wizard. The following sections explain the procedure to add EOB details in the Claim wizard. When EOB information is pulled electronically (a feature in the e-Claims package), the adjudication details will be filled in automatically.
Adding primary EOB Information
- Click on the 'Add EOB' option in the 'Adjudication Details' section. By default, all CPTs in the Claim, are shown in the 'Add EOB' dialog box.
- As per the EOB, enter the Payment, Patient Responsibility, and Adjustment for all CPTs available in the EOB. Sometimes, the EOB may not have payment information for all CPTs available in the Claim. In such cases, we receive more than one EOB from the Payer. When there are two EOBs, 'Add EOB' should be done twice to add the details in the Claim wizard.
- Finish adding EOB information to the Claim and save the Claim.
Refer to the sample EOB shown below. It has two CPTs with a payment of $4.30 for CPT 87880 and $113.06 for CPT 99214, along with adjustments and PR.
- Clicking on the 'Add EOB' option opens the 'EOB Detail View' dialog with all Claim CPTs populated by default.
- For CPT 87880, the payment is $25.05. It is entered in the 'Paid Amount' field.
- This CPT has an adjustment of $0.95, which is to be added using the 'Add Adjustment' option with the 'CO-Contractual Obligation' Group.
- Similarly, another CPT 99214 has a payment of $113.06. It gets entered in the 'Paid Amount' field. It also has a Patient responsibility of $20 and a Contractual Obligation of $28.94. It gets entered in a separate adjustment with the Group as 'PR-Patient Responsibility' and 'CO-Contractual Obligation' respectively.
- Update the EOB details.
The EOB information added will be shown in a line item.
Note: Secondary Claims not listed in the Claim report available under the 'Billing > Reports' section.