Only $35.99/year

Health Care Claim Preparation and Transmission

Terms in this set (44)

Claim sent to a secondary payer. Claims are received and processed by the primary payer -- the plan that is the patient's primary insurance -- which sends back an RA (remittance advice) detailing the reasons for the payment that is made. When a patient is covered by more than one health plan, the second and any other plans must be sent claims. These secondary claims report what the primary payer paid on the claim. This fact is used by the secondary payer to calculate what, if anything, its payment obligations may be.

If a paper RA is received, the procedure is to use the CMS-1500 to bill the secondary health plan that covers the beneficiary. The medical administrative assistant completes the claim form and sends it with the primary RA attached.

With electronic claims, the medical administrative assistant transmits a claim to the secondary payer with the primary RA (remittance advice), sent either electronically or on paper, according to the payer's procedures. The secondary payer determines whether additional benefits are due under the policy's coordination of benefits (COB) provisions and sends payment with another RA to the billing provider.

The practice does not send a claim to the secondary payer when the primary payer handles the coordination of benefits transaction. In this case, the primary payer electronically sends the COB transaction, which is the same HIPAA 837 that reports the primary claim, to the secondary payer.

Medicare has a consolidated claims crossover process that is managed by a special coordination of benefits contractor (COBC). Plans that are supplemental to Medicare sign one national crossover agreement.