Another insurer is primary

What it means

If you or a family member is covered by two plans, one is “primary” and pays first. The other is “secondary” and may pay some of what is left. The plan is saying it is not the primary, or it needs the primary plan’s decision before it pays.

Several things can sit behind the message. The plan may think you have other coverage that you do not. The order may be unclear, for example for a child covered by both parents’ plans, where each plan’s own rule decides the order. Or a plan may have paid and later sent a refund demand after it learned of other coverage.

We could not confirm a federal rule that sets the order of payment. Each plan’s document describes its rule, so confirm it with your plan and the other plan.

Who has to act first

You, because only you know all your coverage and when each began or ended. Do these in order:

1. List every plan that covers the patient, with the dates each coverage began and ended.
2. Call each plan. Tell it about the other. Ask which it considers primary and why.
3. Ask each plan to confirm that in writing.
4. Give your provider’s office both cards and the written statements.
5. Ask the office to send the claim to the primary plan first, then to the secondary plan with the primary plan’s Explanation of Benefits (EOB).

If a plan issued a denial notice, your appeal deadline is at least 180 days after you receive it for a job-based plan or a non-grandfathered individual plan (check the date on your notice, which controls). Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines.

Arguments that work

• Written statements from both plans. If both say the same plan is primary, send that to the other plan and the provider.
• Correct coverage dates. If a plan’s records show other coverage that ended, send proof of the end date from the plan or your employer’s benefits office, and ask it to update its file.
• The primary plan’s decision. The second plan often needs it. Ask the first plan for its EOB and send it on.
• A denial from the first plan. Send the second plan the first plan’s denial and ask in writing how it will treat the claim.
• Continuation coverage. If one plan is continuation coverage from a former job, see the guide on two plans and COBRA (the Consolidated Omnibus Budget Reconciliation Act).
• Ask for a bill hold. Ask the provider in writing to hold the bills while the plans settle the order; it is not required to, and an unpaid bill can go to collections, so ask before you withhold any payment.

Evidence to gather

• Both insurance cards (you).
• Dates each coverage began and ended (the plans or your employer’s benefits office).
• The other plan’s EOB or denial (the other plan, you).
• Written statements of which plan is primary (each plan).
• Any other-insurance questionnaire you filled in, with the date (you).
• Your call log (you).

What to send

Send each plan a short letter that names the other coverage, asks which plan pays first, and asks for that in writing. Copy your provider’s billing office. When one plan has decided, send its EOB to the other. Check a refund demand against the plan’s file and the coverage dates before you pay, and answer it in writing by the date on the demand.

When this is not worth an appeal

Until the two plans agree on the order, an appeal is premature. Clear up the order first. Appeal only if a plan still refuses to pay after the order is settled and the other plan’s decision has been sent.