Wiki Secondary insurance COB adjustment when Primary denied

[natalie_k_clark]

Patient's primary insurance denied service due to benefit max reached. Secondary is applying COB adjustment even though there was no payment from the primary. If the service is a covered benefit with the secondary, wouldn't we expect them to pay when the primary made no payment?

 

[surbhidhupar02@gmail.com]

Yes, secondary insurance should pay if it's covered in their benefit plan. Sometimes, if the primary insurance denies then we can claim to the secondary insurance if they also denies the benefit then the patient is liable for the payment.

 

[Louke]

Patient's primary insurance denied service due to benefit max reached. Secondary is applying COB adjustment even though there was no payment from the primary. If the service is a covered benefit with the secondary, wouldn't we expect them to pay when the primary made no payment?

The secondary payer should pick up and pay the services after the primary denial especially if the denied charges by the primary "benefits max" are member's liability per eob. But I have also seen some secondary payers don't pay after primary unless it's for the copay, deductibles balances, it all depends on the secondary payer benefits and claims processing.

 

[amyjph]

It depends. As suggested above, you would have to check the secondary coverage. It may not cover in that type situation. Did the primary put the whole thing to patient liability? What was it for, that may make a difference too. The secondary may not pay the entire billed amount, are they adjusting it to what "would have been" by the primary?