Secondary eclaims

[atd]

As of July 15th, we are required to send all claims electronically. Currently the only ones we send on paper are secondary claims. I tried sending a couple of secondary claims electronically as a test and one was processed as primary, the second denied stating there was a primary insurance - that makes me think the claims are coming across as primary, not secondary. Is there a problem with secondary claims in Open Dental, or is it a problem with my clearinghouse (Tesia). Do most ins. companies required an electronic attachment for the primary EOB, or is the primary paid amount enough (and is that info sent?)

Thanks!

[Debbie OD Support]

I believe any Secondary insurance is going to want to see the Primary EOB. I would recommend electroniclly attaching it to the secondary claim. Also I am unaware of Open Dental having a problem sending Secondary claims electoniclly that are mistaken for Primary. When you create claims in Open Dental it clearly shows that they are Primary or Secondary and should be going to the clearinghouse this way. I would make sure that in the patient's account that it does say Secondary on the claim and then resend it to Tesia and call them up to ask if it came over correctly.

[savvy]

When you create claims in Open Dental it clearly shows that they are Primary or Secondary

Question:

Just exactly how is this clearly shown?

When I print the claims to paper, each claim looks exactly the same.....except with different ins co names.
If the patient is insured by both self and spouse/other, then it may be easier to tell primary from secondary.
But if the patient has two coverages, either both under the patient's name, or both under the spouse/other name, determining primary from secondary is not obvious at all.

[sparkly]

if you open the claim from the patient's account, all the info at the very top header gives that info, no? Guarantor name, Ins company, and relationship to subscriber. There's a window for 1* and 2*('other coverage') in that header. Also, there's 'Claim type' which follows what was input in the Family module (1*, 2*, pre-auth, other, capitation).

[atd]

When you create claims in Open Dental it clearly shows that they are Primary or Secondary and should be going to the clearinghouse this way.

Does that mean that e-claims provide more info than paper claims? The paper claim does not indicate which is primary and which is secondary, just that they have dual coverage.

The state of MN has a program for submitting e-claims via the web - when we submit secondary claims that way, we just have to enter the amount the primary paid and adjustment amounts, there's no need to send an EOB. But that only covers a small portion of the secondary claims we have. Do most people use the NEA fast attach service? Or ar you dropping secondary claims to paper and sending an EOB?

[Debbie OD Support]

Yes, Electronic claims show more information than the printed claim form. I am not 100% sure what the clearinghouse sees when they get the information if it is primary or secondary but it should not being getting mixed up as long as you have it setup correctly in Open Dental.

And what I meant about Open Dental showing clearly in Open Dental that it is primary or secondary because in our Account Module it will say Primary and Secondary on the created claim in red letters. Also in the Edit Claim window it highlights that it is Primary or Secondary. I would just ask your clearing house how they can tell if it is Primary or Secondary and make sure that they are receiving the correct information.

[atd]

Based on the rejections I've been getting, the primary COB information doesn't appear to be sent with the secondary claim in Open Dental. It says the primary paid amount and paid date are missing.
In MN, we are required to send secondary claims electronically and are now being asked to send primary COB information electronically as well. Which means that they do not want us faxing/mailing the primary EOB separately, even with their claim attachment process. So in addition to the primary paid amount and date we need to be sending the adjustment reason codes and amounts also. Here's a link to info on the guidelines: http://www.health.state.mn.us/auc/dentguide.htm
The very top link on that page outlines the COB guidelines (Provider COB Claims Data Population).
Please help!

[jordansparks]

I put it down as a bug:
On secondary e-claims, primary paid amount and paid date are missing (unconfirmed)
But I also really don't understand what you mean by "adjustment reason codes and amounts". What's an adjustment?
It would really help if I could see more specifics on your rejections. It's going to be very hard to track down this "bug" without more information.

[savvy]

Not sure if this applies to atd's issue, but....

I have spoken with Delta Dental of Ca regarding, specifically, my offices secondary electronic claims to them.
They keep a copy of all claims submitted.
I was told by them that there is no data appearing on the submitted electronic claim that indicates any amount of payment by the primary insurance, nor does it even indicate any payment by the primary at all.
I was told, on multiple occaissions (most recent as last week), that the only info is the name of the other insurance company.
This is exactly as it appears if I were to print the claims to paper.

[JimZ]

Is it possible that the reason for no information on benefits paid being shown is because the Secondary Claim is made in the software the same time as the Primary Claim? The Secondary Claim should not be formed until the Primary Benefits are entered to reflect the payments on the first claim. Then again, I'm JAD (Just a Dentist) with little programming abilities.
Jim

[savvy]

That makes perfect sense to me.

[jordansparks]

The Secondary Claim should not be formed until the Primary payments are entered.

Yes, this has been assumed in all programming.

[savvy]

You know what they say when one "assumes".......

[atd]

The adjustments/codes I was referring to would be if a PPO writeoff is done, what the primary lists as the patient responsibility, etc. These are the most common:
41 - Discount agreed to in Preferred Provider contract
96 - Non-covered charges.
3 - Co-payment Amount
Here's a link to all the HIPAA claim adjustment reason codes: http://www.wpc-edi.com/content/view/695/1

It's my understanding that these adjustment amounts need to be sent in loop 2320 of the secondary claim, along with the primary paid amount. That enables to the secondary to process the claim without the need for the primary EOB.

The error code I'm getting from ClaimX is:
E0106 - Secondary Claims Require Primary Paid Amt. and Date
If I send through Tesia the claim just gets paid as primary rather than secondary since it doesn't receive the primary info.

[jordansparks]

I should have asked if it was ClaimX. Remember that they generate their own 837s directly from our database. We can't fix a ClaimX issue because we don't have control over that programming code. Let's concentrate on Tesia.

On all secondary claims, we already send out the amount the payor amount paid in 2320 AMT, like this:
AMT*D*411~
We do not send out 2330B DTP (claim paid date). Perhaps this is what they want to see. Documentation says it's required when 2430 is not used (it's not).
We do not send out 2320 CAS (claim level adjustment) or 2430 CAS (procedure level adjustment). This is where the "adjustment reasons" would go if we supported them (we do not).
We do not send out 2430 SVD (line adjudication information).

It's complicated. A lot of the segments seem to have to do with payer-to-payer transmissions which we would never be doing. But some of the ones listed above might be relevant, particularly 2330B DTP.

I will put down the missing 2330B DTP as a bug.

[jordansparks]

Bug hopefully fixed. The date paid is now included. Version 6.7.8. I'm hesitant to backport it to version 6.6 for fear of destabilizing that version.

[atd]

We're still having issues with secondary insurance paying as primary. I pulled up the e-claim files for a couple examples and found AMT*D*0.00~ in cases where primary did pay.

I can't say for sure that the insurance companies will process correctly even if the primary amount is being sent, but they surely won't if we're always sending 0.00. Please add to the bug list. Using version 7.4.12

[jordansparks]

Added to bug list.

[jsalmon]

The bug of "Secondary e-claims were not sending primary amounts" was fixed and released in versions 7.5.18, 7.4.16 and 7.3.14.

[atd]

I upgraded and sent a test claim this week and it worked! I verified online with the insurance company that they're paying the correct amount, as secondary rather than primary. Thank you for fixing this, it will save our staff so much time!

[Smilesbypayet]

We are having a major problem with OD not estimating secondary insurance coverage correctly, and today one of my team was told by an OD supervisor that the software is not even set up to estimate secondary insurance coverage correctly?

PLEASE tell me she misunderstood? To help patients during these economic times, and especially as we are finding more and more patients with secondary insurance, we have started filing them, but we do need correct estimations!

[atd]

Our office paid $500 to have secondary estimates programmed in version 6.8 because it was critical to us. Prior to that they had to be manually calculated or we had a negative balance on the account every time. We still see issues with secondary estimates, but it's usually after the primary has paid something different than our estimates - so we end up having to manually adjust the secondary estimates.

[Smilesbypayet]

Our office paid $500 to have secondary estimates programmed in version 6.8 because it was critical to us. Prior to that they had to be manually calculated or we had a negative balance on the account every time. We still see issues with secondary estimates, but it's usually after the primary has paid something different than our estimates - so we end up having to manually adjust the secondary estimates.

So you are saying that, since we are running on v7.5, it absolutely should estimate secondary claims correctly unless the primary doesn't pay exactly what is estimated? Does that mean that the secondary estimate will be off in proportion to how much the primary was off?

[atd]

Prior to version 6.8 the secondary estimates didn't factor in the primary estimates at all - so we were getting double the writeoffs and the estimated payments were too high. Since you're on version 7.5 that is no longer the case. I haven't done rigorous testing of secondary estimates myself, so I'm not going to say that they are absolutely correct - that would be for Open Dental to attest to. But from my experience, if you have all the information to setup the insurance plan correctly (i.e. allowed fees, correct percentages, deductibles, maximums, etc.) Open Dental does a great job of calculating what the patient should owe.

Delta Dental won't give us a PPO fee schedule, so I know that our estimates are not correct for the primary which will end up changing things for the secondary after the primary payment is posted. So, we usually wait until both primary and secondary pay before sending a statement for people with two insurance plans. I'm not saying that's because Open Dental isn't calculating it correctly, I think it's more our issue of not having all the info we need.

If you know you've setup both insurance plans correctly, yet you can find specific examples of how the secondary estimates are incorrect, provide Open Dental with that information and I'm sure they would look into it.