Filing Tertiary Claims
Billing insurance companies for reimbursement is a pain to deal with. When you bring secondary and tertiary claims into the mix it can become a nightmare. Applied Medical Systems is here to help you and your practice by providing not only primary billing services, but secondary and tertiary as well to make sure you get fully reimbursed for your medical services.
Filing both secondary and tertiary claims requires careful attention to detail and proper documentation. Here’s a step-by-step process for a medical office to accomplish this:
Secondary Claims – Secondary claims can be submitted electronically or on paper. However, Medicare requires electronic submission for secondary claims. If a secondary claim is submitted on paper, the claim is printed onto a CMS form and a copy of the explanation of benefits (EOB) is attached.
Tertiary Claims – Tertiary claims are submitted if the patient has a third insurance provider and if there is a balance left. This claim is sent to a third carrier and it is printed off on a CMS form with both EOBs from the primary and secondary carrier.
1. Verify Primary and Secondary Insurance Payments
What insurance to bill next?
When a primary claim is filed and the patient’s primary insurance does not cover the full cost of the medical service, your next step may be to bill the patient’s secondary and then tertiary insurance. As a physician, you know that billing out to these secondary and tertiary providers can be confusing when determining who to bill next.
Primary Claims
Your primary insurance company is usually the insurance of the parent who is working in the family. However, if both are working then the primary insurance is each parent’s own employer insurance. If the parent has Medicare and their employer has under 100 employees, primary insurance may be Medicare. For children or dependents, the primary insurance is sometimes billed to the parent whose birthday falls first in the year. However, if the parents are divorced, a court order may determine the order of insurance billed. Once the primary provider pays their portion of the claim, then it is billed to the secondary insurance if the patient has it.
From there:
- Check the Explanation of Benefits (EOB) from the primary insurer:
Ensure the claim has been processed and paid according to the patient’s plan. Note the allowed amount, the amount paid, and any patient responsibility (copay, coinsurance, deductible). - Check the EOB from the secondary insurer:
Confirm that the secondary insurer has also processed the claim and paid their portion based on the primary insurer’s EOB and the patient’s secondary coverage. Again, note the allowed amount, payment, and any remaining patient responsibility.
2. Identify the Need for Tertiary Billing
- Review the patient’s insurance information:
Confirm that the patient has a valid tertiary insurance policy. - Check for remaining patient responsibility:
If there’s still an outstanding balance after the primary and secondary insurers have paid, and the tertiary insurance should cover it (or a portion of it), proceed with filing the tertiary claim.
3. Gather Necessary Documentation
- Original Claim Form (CMS-1500 or electronic equivalent)
- EOB from the Primary Insurer
- EOB from the Secondary Insurer
- Copy of the Patient’s Tertiary Insurance Card
- Any relevant supporting documentation (e.g., medical records, pre-auths)
4. Complete the Tertiary Claim Form (if required)
- Review the tertiary insurer’s guidelines
Some payers may require special forms or steps for electronic submission. - Fill out the claim form accurately:
Include correct patient demographics, provider info, CPT/HCPCS codes, and diagnosis codes. - Indicate that this is a tertiary claim
Most claim forms allow you to specify this in the insurance order. - Attach the primary and secondary EOBs
These help the tertiary payer determine payment responsibility.
5. Submit the Tertiary Claim
- Follow the insurer’s submission method:
This might be electronic (EDI), by mail, or through an online portal. - If submitting electronically:
Make sure your clearinghouse or billing software can handle tertiary claims and attach all required documents. - If mailing:
Send the complete claim with attachments to the correct address. Keep a copy for your records.
6. Track the Claim
- Monitor claim status:
If no EOB is received within the expected timeframe, follow up with the insurer. - Keep the claim reference number
This will be helpful when calling the payer.
7. Review the Tertiary EOB
- Check for accuracy:
Ensure the tertiary insurer processed the claim correctly, based on what primary and secondary paid. - Note the final amounts paid and any remaining patient responsibility.
8. Handle Any Remaining Balance
- Bill the patient for any copay, coinsurance, or deductible remaining after tertiary payment.
- Issue refunds if the tertiary payer overpaid.
- Update the patient’s account accordingly.
Key Considerations for Tertiary Claims
- Payer Rules: Each tertiary insurer may have unique requirements for submission. Always confirm them.
- Coordination of Benefits (COB): Know how all insurers interact.
- Timeliness: File within the tertiary payer’s deadline.
- Accuracy: Mistakes can lead to delays or denials.
- Communication: Keep the patient and all insurers in the loop throughout the process.
Benefits of Practice Management
As you can see, this process is a headache to go through day in and day out for only small claims’ reimbursements. However, the neglecting of these secondary and tertiary claims can add up over time. This can mean thousands of dollars of revenue lost from your practice.
Electronic submission has made this process significantly easier and more efficient. Applied Medical Systems not only has trained professionals to take care of secondary and tertiary claims, we also have the latest electronic claims submission technology to make the process more streamlined and accurate. For more information or to learn more about our medical billing services, contact us at our Durham, NC office.