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Managing Secondary Claims and EOBs

This guide walks through how you can invoice and record EOBs for visits with dual coverage - where the client has insurance policies with multiple insurance companies (i.e. primary and secondary insurance).

Please note that at this time Jane does not support electronic (EDI) secondary claim submission. Secondary Claim Submission Support, is on our roadmap, so please add yourself to our existing feature request so we can be sure to notify you when this feature becomes available. Secondary claim submission is best handled outside of Jane for now (i.e. manually within your clearinghouse).

Invoicing a visit with dual coverage at the time of service

When a client is covered under a single policy (their ‘primary’ policy), you can simply add the client’s policy to the appointment to create a claim under that policy. At the time of service, you’d then enter the relevant billing codes, and collect any known patient responsibility (i.e. a copay). Likewise, you have the opportunity to add in billing code Allowed Amounts.

When a client has dual coverage, time of service invoicing changes slightly! For visits with dual coverage, if you add patient responsibility (i.e. a Copay) to the primary claim, that amount will be passed to the secondary instead of the patient.

That said, the primary Copay can be passed directly to the patient (bypassing the secondary) when recording the remittance/EOB for the primary. To bypass the secondary insurer, just be sure to select the Collect from Patient option under your patient responsibility (i.e. Copay) when posting the primary EOB.

 

Let’s walk through an example - Time of Service

Let’s say Dr. Marcus bills out two codes - 99203 & 98941 - with respective rates of $150 and $50 to his client Jordan Smith’s primary insurance.

Dr. Marcus is in-network with Jordan’s insurance (Blue Cross / Blue Shield) so he knows how much they will allow for both the codes he’s billing out - $85 for 99203 and $45 for 98941. Dr. Marcus also knows that Jordan has a 20% coinsurance that he would like to collect at the time of service.

Here’s how that would look:

Note how the Allowed Amounts affect the invoice. They represent the total amount that Dr. Marcus expects to collect from both the patient and the insurance company (insurer payment + patient responsibility). The patient invoice is $26 (20% of $85 + 20% of $45), and the insurer invoice is $104 (Billed Amount - Un-Allowed Amounts - Patient Responsibility). The difference between the Billed Amounts and the Allowed Amounts, or ‘Un-Allowed Amount’ ($200-$30 = $70), is adjusted off of the invoicing at the time of service.

Note that the invoiced amounts won’t affect your claim submissions, as Jane only uses the Billed Amounts on CMS1500s and EDI files.

Now let’s spice up the scenario and say that Jordan also has secondary insurance coverage. 🌶

When we add Jordan’s secondary insurance coverage to the visit, here’s what happens.

  • The primary insurer invoice is unchanged (still $104)
  • The patient invoice changes from $26 to $0 (Jane assumes the secondary will cover the Coinsurance)
  • The secondary invoice is created for $200 (assuming no Allowed Amounts are present).
  • The total Billed Amount (sum of the procedures) is $200 and the total visit invoicing of this visit is $304 (primary + secondary + patient invoices)

You may be wondering why the total invoicing of the visit is greater than the procedures being billed ($304 when combining the primary and secondary invoices vs the $200 in procedure codes). 🤔

This is because Jane treats the invoicing of each claim independently at the time of service. Each claim (i.e. the primary and secondary claim) has its own set of billing code Allowed Amounts that reflect the billed procedures. The Allowed Amounts determine the invoice amounts for both claims at the time of service.

This mirrors how claims are treated in the submission process. When billing a secondary claim, you still need to bill the full amount of the billing codes along with the primary EOB/Remittance.

If Dr. Marcus knows what Jordan’s secondary insurance is going to allow for each procedure, he can add Allowed Amounts to the secondary claim at the time of service to make his accounts receivable for the secondary invoice more accurate before recording the response from the primary insurer (recording the primary EOB).

Let’s say that Dr. Marcus knows that the secondary insurer allows $40 for 99204 and $5 for 98941.

Here’s how the invoicing would change if you added those Allowed Amounts to the secondary claim:

  • The primary insurer invoice is unchanged (still $104)
  • The patient invoice remains $0 (since no patient responsibility was entered in the secondary)
  • The secondary invoice updates from $200 to $45
  • The total Billed Amount (billing codes) is $200 and the total visit invoicing is $149

 

Posting primary EOBs for visits with dual coverage

If a patient has dual coverage, then you’ll want to consider their secondary policy when recording the EOB (remittance) from the primary.

When recording a primary EOB, you’ll be able to tell if the patient has secondary coverage if you see the option(s) to pass a portion of the visit to the Next Payer. In Jane, the ‘Next Payer’ refers to the patient’s secondary coverage.

If the primary insurer doesn’t cover the full amount, or if you’d like to pass down the patient responsibility to the secondary, be sure to choose the ‘Collect from Next Payer’ option before applying your changes to the primary EOB.

Likewise, for each procedure you bill, you can choose to pass down the difference between the Billed Amount and Allowed Amount as well as the difference between the Allowed Amount and Paid Amount to the Next Payer. Just click the dropdown under the Allowed Amount and/or Paid Amount and select the ‘Collect from Next Payer’ option as needed! Please note if you choose to adjust these amounts on the primary EOB, the remaining balance of the visit after posting the primary remittance will not be passed to the secondary.

 

Let’s walk through an example - EOBs

Let’s say I bill two codes, one for $150 and one for $75.

When I hear back from the primary, this is what they outlined in the remittance:

Code 1 - $150

  • Allowed Amount $105
  • Paid Amount $80
  • Copay $25
  • Contractual Adjustment $45 ($150-$105)

Code 2 - $75

  • Allowed Amount $68
  • Paid Amount $58
  • Copay $10
  • Contractual Adjustment $7 ($75-$68)

Now let’s say that I want to pass down the reported patient responsibly (Copay in this example) to the patient’s secondary to see if they’ll cover it. To do this, I need to make sure I select the ‘Collect from Next Payer’ option instead of the ‘Collect from Patient’ option for both procedure Copays.

Note that you don’t need to pass everything the primary insurer doesn’t cover to the Next Payer.

In this example, I only want to pass the patient responsibility to the secondary, so I choose to adjust off the differences between the Billed Amounts and the Allowed Amounts when recording the primary EOB. The total amount I’ve chosen to adjust (what we call the ‘Total Insurance Adjustment’ in Jane) will not be passed along to the secondary insurer and instead will be adjusted off after I apply my changes.

Now, let’s say that I have billed the secondary insurer and I’ve received a remittance. When I enter the EOB screen for the secondary, this is what we’ll see:

Instead of seeing the full Billed Amounts ($150 and $75 respectively) of these procedures, we just see the amounts that were passed down from the primary payer - which we decided to pass down did when we posted the primary EOB.

Now we can record our secondary EOB as needed and we’re done with this visit!

 

I am trying to record an EOB for a Secondary Claim, but the numbers don’t look right. What can I do?

If you’re having a little trouble recording an EOB for a secondary, the most likely culprit is the information in the EOB for the primary policy.

If the numbers passed from the previous payer don’t look quite right, it’s a good idea to give the primary policy EOB a quick glance. You can view the primary EOB by heading to the appointment or purchase, clicking the dropdown beside the primary policy, and selecting the ‘Edit EOB’ option.

Double check that you’ve passed the right amount down to the Next Payer. If you realize you’ve made a mistake, you can simply fix it up and re-apply the changes to the primary EOB.

Pro Tip⭐️: If you’ve entered the EOB screen for a secondary claim, and it looks like the screenshot below, you most likely need to edit the primary EOB and make sure you pass down some or all of the remaining balance to the Next Payer (instead of passing it to the patient or adjusting it off).

 

If you have any questions about managing secondary claims or EOBs, we’re happy to help! Use the Help button from within your Jane account or email us at support@janeapp.com. 🙂