Questions and Answers from the eAssist Claims Pipeline

Primary and Secondary Insurance

Question:

I have a 24yr old patient who, according to the software setup is married, has her primary through her husband and then a secondary insurance through her mother. The husband’s DOB is 1/16/90 and mom’s DOB is 3/3/75 so in keeping with the birthday rule the set-up is correct. But…..once a person gets married can they still be covered under the parent until age 26?

Answer:

Yes they can!  From my experience the plan that has been in effect the Longest would be the primary in this situation.

Question:

I have a patient in one of my offices that has dual insurance and both are paying as primary, one is Delta CA and the other is Aetna. When I call to speak to both of them, they are both claiming they are the primary plan.  It is for a child (14 years old). The Delta plan is through the step-father, whom the child resides with along with mom. The Aetna plan is through the natural father. There is no court order involved. I gave this information to both insurances, but they both still claim to be primary. Has anyone run into this before?

Answer:

I have had plans do this. Usually the subscribers have to get involved to straighten it out which can be difficult to get them to do due to divorce. You can also ask what rule each insurance uses and if they are the same, say the birthday rule, then you may be able to speak to a supervisor to sort it out. Some insurance companies say it depends on who the child lives with no matter what, but some still go by the birthday rule. That’s a tough one when there’s not a court order. There have been times I’ve had to just leave the credit on the account and flag it until the subscribers sort it out themselves.