Wiki BCBS PRIMARY AND BCBS SECONDARY

[kcowan]

WE HAVE A PATIENT THAT HAS BCBS THRU FATHER (OUT OF STATE BCBS), MOTHER HAS BCBS OF TEXAS SECONDARY. THE PRIMARY HAS PAID ON CLAIMS, THEN WE FILE TO THE SECONDARY (HEB) BUT THE 2ND IS MAKING NO PAYMENT?

PRIMARY BENEFITS DED (FAMILY) 4500 DED MET 90/10
SECONDARY BENEFITS OV COPAY $55, $350 DED MET 80/20

THE ALLOWED AMOUNTS FOR PROCEDURES ARE THE SAME FOR BOTH INSURANCES, THE PRIMARY PAID 90% ON THE CHARGES THE E/M 99214 HAD A BALANCE OF $10.13. THE PROCEDURE HAD A BALANCE OF $25.98, I THOUGHT THAT THE SECONDARY WOULD COME AN PAY 80% OF THE BALANCE LEFT ON THE PROCEDURE, BUT BCBS 2ND IS TELLING NOPE NOT.

 

[CBLENNIE]

It could be that the mom's plan rules for coordination of benefits for when it is secondary are based what is often called "non-duplication of benefits" or "maintenance of benefits (MOB)."

If this is the case, this type of coordination means that the secondary plan's rules are that they will not pay more on the claim than they would've if they had been primary. So, if the secondary plan (mom's) would have paid the same or less than the primary plan (dad's) paid mom's plan will not pay anything on the claim. There are usually remark codes on the remit that indicate that the benefits were coordinated, and no additional payment was made on the claim.

You need to find out what the coordination of benefits provision of mom's plan are to determine if this is the case or not. If the coordination of benefits rule is not the issue, then you'll have to contact mom's plan to find out why they didn't pay anything on the claim.