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Lori Posted Fri 09th of February, 2018 18:00:53 PM
We need to know the legal rule surrounding the submission of claims to tertiary payers. Most of the time it cost more money in postage to mail a tertiary than the reimbursement the provider gets back. Is it a legal requirement that a provider "must" submit a claim to a patient's tertiary?
SuperCoder Answered Mon 12th of February, 2018 08:12:02 AM

Hi,

Here is some information regarding the billing of tertiary claims :

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. When you have Anthem secondary/tertiary professional claims with coordination of benefits (COB) or other coverage information, you can file these claims electronically and eliminate mailing paper claims. One of the benefits of the electronic claim format (837) required by HIPAA is its COB capability without using paper claims or copies of Explanation of Benefits (EOBs).

Also, in situations where Medicare is the tertiary payer, these claims may be submitted hard copy.

Further query is welcome.

Good day.

Lori Posted Mon 12th of February, 2018 15:26:26 PM
Hello, This response is telling me "how" to submit a tertiary claim, but my question is whether or not a provider is "required" to submit a tertiary claim on behalf of a patient.
SuperCoder Answered Tue 13th of February, 2018 04:14:03 AM

Hi Lori,

Here is some information from CMS, stating that a hardcopy claim must be submitted on Form CMS-1500. Physicians and other suppliers must attach the other payers’ EOB, or remittance advice, to the claim when sending it to Medicare for processing. Please refer to the attached article for further information.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf

Hope this helps!

 

Lori Posted Wed 14th of February, 2018 15:02:35 PM
I appreciate your response, but the link you provided does not tell me what I'm asking. I'm asking if it is a "legal requirement" that a provider bills a tertiary claim for a patient? It's my understanding a provider is "required" to bill a patient's insurance "if" the provider is contracted with that payer. However, I've also been told when it comes to billing tertiary claims that a provider "is NOT" required by regulations to do so. Thank you for the help.
SuperCoder Answered Thu 15th of February, 2018 00:27:57 AM

 

 

Hi Lori,

According to the attached article, Medicare clearly states that claims with multiple primary payers cannot be sent electronically to Medicare. A hardcopy claim must be submitted on Form CMS-1500. Physicians and other suppliers must attach the other payers’ EOB, or remittance advice, to the claim when sending it to Medicare for processing Medicare Secondary Payer claims.

 

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