Optometry Coding & Billing Alert

Published on Fri Nov 16, 2007 PDF

Be careful: Some states observe -gender rule- instead

If your optometrist provides services to children, you often have to decide which parent's insurance plan covers a child. Take a look at this handy cheat sheet to ensure you pick the correct one every time.

You will typically follow the "birthday rule" for children whose parents are not separated or divorced, or dependent children of parents with joint custody.

Breakdown: The birthday rule says that for a dependent child of parents who are not legally separated or divorced, the insurance of the parent whose birthday falls earlier in the year is the primary carrier, says Deb Flanagan, recovery unit manager for Inland Cardiology Associates in Spokane, Wash.

Tip: If both parents have the same birthday, the plan that has provided coverage longest is the primary carrier.

Remember: "Birthday" in the birthday rule refers to the month and day in a calendar year, not the year in which the parent was born, Flanagan says.

"So, if one parent's date of birth is April 28, 1961, and another's is Jan. 28, 1970, the plan of the parent whose birthday is in January is primary even though she is years younger," says Susan E. Garrison, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, executive vice president, healthcare consulting services for Magnus Confidential in Dawsonville, Ga.

Caution: Some plans may instead go by the "gender rule" for dependent children. This rule states that the father's coverage is the primary carrier.

Try this: If you are having trouble keeping all of the carriers- rules straight for dependent children, you might benefit from creating a spreadsheet that identifies which carrier uses each rule.

If your doctor treats a child covered by more than one group plan and the parents are either separated or divorced, bill the plans in the following order:

- First: The plan of the parent with child custody

- Second: The plan of the spouse of the parent with child custody

- Last: The plan of the parent not having child custody.

Exception: If there are court-decree terms that state that one parent is responsible for the child's healthcare expenses, you should bill that plan as the primary carrier. It may be a good idea to call the responsible parent for pre-approval before filing any claims.

Helpful hint: "When seeing children, it would be extremely helpful to get this information up-front using a simple form that would be completed when the child came in for the first visit," Flanagan says.

"Good coordination of benefits by the billing staff is incredibly important," Garrison says. "Otherwise, you may end up double-billing, which could be construed as abuse."

Best bet: "Put in place a questionnaire asking for all insurance information [from both parents for children, or have the parent/patient indicate no other coverage by the other parent]. Then, contact the payers to determine who is primary," Garrison says.