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🇺🇸 Managing Secondary Claims and EOBs

This guide walks through how you can manage patients & troubleshoot claims that have secondary or supplemental insurance coverage - where the client has multiple insurance policies(i.e. primary and secondary insurance).

While the workflow detailed below requires more of a manual touch, Jane has made this easier for you to handle if you submit claims electronically & receive remittances or ERA’s through Jane!

Generating CMS1500 forms for secondary claim submission

🎉 Jane now supports electronic (EDI) secondary claim submission! Click here to learn more about this feature. 🎉

Jane lets clinics submit secondary claims electronically or generate a CMS1500 form for paper submission.

To generate a CMS1500 form for the secondary payer, click the dropdown beside the Pay button when viewing a purchase with dual coverage.

Likewise, when working in the Claim Submission Folders, a CMS1500 will be produced for any selected secondary claims when creating batch CMS1500s. You can learn more about batch CMS1500s here.

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’ve received a response from the previous payer via an ERA and you have posted that remittance within Jane, you can refer back to the primarys’ remittance by clicking the same dropdown beside the Primary Policy, and selecting View Claim Response.

If you need to adjust any of the numbers passed along to the secondary, the same steps as above would apply here!

 

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 [email protected]. 🙂