Commercial/Private Payer
When patient have more than one insurance, perform coordination of benefits (COB) to make sure patient has correctly determined which one is primary, secondary, tertiary and so on. The determination of primary or secondary payer for two or more commercial policies of the patient status is different for adults and children.
- Adult patient named as policyholder: The patient is the policyholder.
- Adult patient names as dependent on the policy: The patient is a dependent on the carrier policy.
- Primary versus secondary insurance: Primary insurance plan is the insurance plan responsible for paying healthcare insurance claim first. Once primary paid its portion of 80% of the claim the secondary will pay the remainder, and so on.
- Child of divorce parents: The custodial parent's plan is primary. If the parents are remarried, the custodial parent's plan is primary, the custodial stepparent's plan is secondary, and noncustodial parent is tertiary. An exception if there is a court order that specifies a parent who will cover the child's medical expenses.
- Child living with both parents: If each parent subscribes to different health insurance. The policies as determined by applying the birthday rule. Birthday rule states that the policy holder whose birth month and day occurs earlier in the calendar year should be the primary for the dependent child. If the policyholders have identical birthdays, the policy in effect longest is primary.
- Gender rule: States that the father's plan is always primary when a child is covered by both parents. If problems occur if one parent's policy uses birthday rule and other uses gender rule contact the health plan administrators to determine which rule to follow.
Medicare as Primary Payer:
Medicare is primary payer based on the circumstances below:
Medicare is primary payer based on the circumstances below:
- The employee belongs to a group health plan but refuse to enroll or dropped coverage recently.
- The individual currently employed, but not yet eligible for group health plan or has exhausted benefits under the plan.
- The health plan is only for self-employed individuals.
- The patient is covered by TRICARE, giving them health benefits to retired members of uniformed services and spouses/childen of active duty, and deceased service members.
- The patient is younger than 65, has Medicare because of disability or ESRD, and not covered by employer-sponsored plan.
- The patient is younger than 65, has ESRD, and has employer-sponsored plan
- The patient left a company but decided to stay covered in the group health plan under federal COBRA rules.
- The patient is eligible for both Medicare and Medicaid.
Medicare is secondary when patient is eligible for Medicare and also covered by one or more of the following policy:
- An employer-sponsored group health plan (EGHP) that has more than 20 employees.
- Disability coverage though employer-sponsored group health plan (EGHP) that has more than 100 employees.
- An ESRD case covered by employer-sponsored group health plan (EGHP) of any number during the 18 months patient is eligible for Medicare.
- Patient is involved with job-related injuries and vehicular accident and covered by Worker's Compensation, and Automobile insurance.
- Third-party liability policy for no-fault insurance.
- Veterans Administration pre-authorized services for a beneficiary who is eligible for both VA and Medicare benefits.
- Federal Black Lung Program that covers currently or formerly employed coal miners.
