Billing dual dental insurance isn’t simple. There is absolutely nothing simple about it. And the hard part isn’t mailing the claim. No. The difficulty and confusion comes in first identifying who is primary and who is secondary. And our dental patients often want to tell us just how to do this. They want the insurance policy with the most benefits billed first. Or they want the divorced dad’s new wife’s insurance billed first. And all kinds of craziness.
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The reality is, none of us get to decide that. So who does? That doesn’t come with an easy answer either. But it’s important to kindly explain to patients that who gets billed first has already been decided. And that none of us made that call. Then, know we are talking about insurance. We have to read the fine print. And we have to understand some terminology and laws. Then, we have to know that there are exceptions to all of the above. And finally, know ultimately, you don’t “have” to do any of this. In fact, I’ve worked with practices who refused to work with secondary insurance altogether.
Some dental practices do refuse to factor in secondary insurance. And they do this because they just don’t want to deal with it. Patient estimates are based on primary insurance coverage alone. The secondary insurance is billed, and if there is a payment that results in a patient over-payment, the patient receives a refund. It has worked fairly well in practices where we have done this. But as much as those of us in the dental field despise working with dental insurance, our patients just love it! And even if you decide not to factor in any secondary insurance payments, you need to know who to bill first!
Patients often misunderstand their insurance coverage. Now, I don’t have to tell you this. As you see this first-hand every day. Many patients don’t even know who their dental insurance carrier is. Nor do they know much about their benefits. And when a secondary insurance carrier is involved, it’s twice as confusing to them. Only they don’t even know just how confused they are. So it’s important that we un-confuse our patients. And that we don’t allow them to take us down with them!
Billing Dual Dental Insurance: Who Gets The Claim First?
Great question! And it all depends on the plan. And to really understand the answer we have to know some terminology. Vocabulary lesson here! A “coordination of benefits” outlined in each dental insurance plan tell us how to bill when another coverage for an individual also exists. Dental insurance companies created this so there wouldn’t be any confusion. I’m not quite sure they have done that. And I’ve even seen many an insurance claim paid incorrectly. They might have even confused themselves. So watch this well! Know the rules and pay close attention to these claims.
Individual dental insurance policies are the exception to this rule. A patient who has an individual plan as one of their two policies has a different situation. Only group (employer) plans are required to follow the coordination of benefits guidelines. The individual plans that a patient may purchase themselves is not bound by a coordination of benefits rule. And they may pay as if there is no other insurance carrier. Therefore, we must be careful with this one. It would be easy to see a credit on a patient account with this scenario. Be sure when sending monies back that they go to the right insurance and not to the patient. Insurance over-payment never goes to a patient.
Group (Employer) Dental Insurance Plans
Only group dental insurance plans are required to coordinate benefits. This is important to know when billing dual dental insurance. And in a nutshell, this is how it all must be billed. Some patients have a “self-funded” dental plan. And they are not bound by these rules.
Medical Before Dental
- Medical insurance is billed before the dental plan. Some medical plans have dental coverage. This is especially true for pediatric care. But is even true for some adult preventive claims. Send the dental claim to the medical plan first. Don’t be scared by this! Jus submit the usual dental claim form with dental codes and terminology to the medical plan.
- Dependent children’s claims follow the birthday rule. Look at the birthday month for each parent. The primary insurance will be the parent with the earliest birthday in the calendar year. Pay no attention to the year or the age of the parent. Then send the claim first to the parent with the earliest birth month. Unless there is a divorce or separation to consider. Then you will need to follow the divorce decree. And the insurance company can request a copy of the divorce decree to confirm.
One Patient – Two Employers
- One patient has more than one employer. And has a different insurance through each employer. Send the claim first to the insurance plan that has been in effect the longest. You need to the effective date of each policy. Note the effective date on each claim when you submit them to avoid delay.
Cobra Plans or Retiree Plans
- COBRA or retiree plans are secondary. You may see a patient with a dental plan through a current employer. Yet they also have a plan through a company from which they retired or had extended coverage. In this situation, bill the plan through the current employer first. And note on the claim that the secondary plan is a COBRA or retiree plan. Also include effective dates to help avoid delays.
Spouse or Domestic Partner Coverage
- Employee & Spouse/Domestic Partner. A patient with a dental plan through themselves and a partner always hold their own plan as the primary coverage. The partner’s dental plan is always secondary. Send the claim first to the patient’s personal plan and then send to the partner’s plan.
Billing Dual Dental Insurance: Secondary Claims
Hopefully, the claim you sent to the primary insurance went well. There were no hang-ups or delays and you now have an insurance check and an explanation of benefits in your possession. Great job! Now you get to bill the secondary plan. Be sure you include a copy of the full explanation of benefits with this claim. And you especially need to include the page that shows all those little codes that explain why the primary paid what they paid.
The primary explanation of benefits must be very clear. If it’s a bad copy or the secondary insurance company can’t read it well, this claim will not be paid. You may scan explanation of benefits for safe-keeping. That’s great! But you must be sure the scan is readable and also includes all the necessary codes. Not all insurance companies will re-issue an explanation of benefits. So be cautious to keep great records.
Include any additional supporting documentation. If this claim requires x-rays, narratives, or seat dates, be sure to include these on the secondary claim too. Double-check everything before you send this secondary claim. It can be super frustrating to receive a request back for additional information. Or to call the insurance company to follow-up and find they are missing something. This is already a very time consuming process. Try to keep it as efficient as possible.
Write-Offs With In-Network Plans
How do we calculate write-offs with contracted dental plans? Let me keep this really simple! First, wait until you receive both insurance payments and explanation of benefits. If a write-off is done when the primary explanation of benefits comes in and then another when the secondary comes in, there will be an error. And there could even be an incorrect credit on the patient’s account.
Honor the largest patient write-off. It’s not the secondary adjustment that we need to honor. But it is the largest write-off. Even if that means the primary insurance adjustment is the largest. And these adjustments and explanation of benefits deserve a good second look. It’s easy for insurance companies to make mistakes too!
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So, in conclusion, let me just say there is much more secondary claim submission than patients think. And many patients think that 2 insurances mean twice the coverage. They may even try to convince you of this. It’s just not true. Some patients may even have an insurance plan with a “non-duplication of benefits” clause.
A “non-duplication of benefits” clause is a whole new consideration. And the focus of this article is how to bill dual insurance. But know that if a “non-duplication of benefits” provision exists on a secondary plan, they will not pay any benefits if the primary paid the same or more than the secondary plan allows.
Check on these things when verifying dental insurance. As tough as it can be to help patient’s understand these provisions, it’s much easier to do before treatment. It’s so painful to backtrack after an insurance denies a claim. And to explain to patients why there wasn’t a payment. Especially if we have told them something else.
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