How to file a claim when you have more than one health insurance coverage depends on the particular situation. To learn about your situation, please see:

• When Both Plans Require Filing A Claim Form  
• When Only One Plan Requires A Co-pay  
  
• When One or Both Plans Is A PPO 
  
• When Both Plans Require Only A Co-pay  
  
• When There Are Three Plans 

To understand which insurer pays what, see Coordination of Benefits. If Medicare is involved, see Coordination of Benefits - Medicare

The steps involved in filing the claims yourself are:

Step 1. Get a claim form for each insurance plan you have. NOTE: Medicare requires the physician to submit the bill directly to Medicare.

Step 2. Get a copy of the itemized bill your doctor would send to an insurance company. This is usually more informative than a bill that just lumps multiple items under one charge or type of charge. It must include:

• Identifying information about the plan.
• Details about you and your coverage.
• An itemized listing for every procedure or test being billed.
• The procedure code for each item.
• A diagnosis code for each procedure.

Step 3. Determine which plan is primary and which is secondary using the guidelines in Coordination of Benefits..

Step 4. Complete the claim form for the primary insurance company and send it to the company with a copy of the itemized bill

• Keep a copy of the itemized bill. The other carrier will also need a copy of the bill.
• Don't try to hide the existence of the secondary carrier from the primary. When the claim form asks if there is other insurance, tell the truth and report it.

Step 5. Upon receipt of the Explanation of Benefits from the primary carrier, submit  to the secondary carrier the following:

• The completed secondary claim form.
• A copy of the itemized bill.
• A copy of the primary carrier's Explanation of Benefits.

For information on how to track medical insurance claims see Keeping Track Of Your Claims For Medical Bills: A Simple Method.

Once you receive an Explanation of Benefit (EOB) from the secondary carrier, compare it with the primary carrier's EOB and the itemized bill:

• Do the payments from the two companies total the entire bill? If so, then the plans have paid correctly.
• If the total was not paid, look to see why:
  • Was there a charge denied completely by both carriers? Remember, if the Secondary plan doesn't cover something, but the Primary plan does, the Secondary plan will pay for it as well out of its savings.
  • Did the Secondary carrier pay as much as it would have if it had been the only carrier? While this won't happen often, remember neither carrier ever has to pay more than it would have if it had been the only carrier.
  • Did the Secondary carrier apply a deductible or coinsurance to the payment? It may consider those in determining its maximum payment, but actual payment should be simply the total covered bill less the Primary's payment.

If the two payments do not equal the total amount of the bill, and you don't see a reason why they don't, it is recommended that you follow the procedure described in Health Insurance: Claims and Health Insurance: Claims Appeals.

When only one plan requires a co-pay of something like $5, $10 or $20, the other plan will never pay you more than your co-pay. There are two ways to accomplish this:

1. Ask your doctor to bill the non-co-pay carrier (the secondary carrier if both plans require co-pays and the treatment is delivered by a doctor that is in both networks), or
2. Pay the doctor the co-pay and get a written receipt for it and file for reimbursement yourself by doing the following:

•  
  • Submit a claim form
  • Include a copy of the receipt for having paid the co-pay
  • Attach a cover letter. A sample cover letter is below.

If you see the doctor regularly, you may want to accumulate several co-pays and request reimbursement for them every few months rather than one at a time.

SAMPLE LETTER REQUESTING REIMBURSEMENT OF CO-PAY(S):

(Name of Insurance Company)
Claims Office
(Address: You can get the mailing address
either from the claim form or by calling the
number on your insurance ID card and
requesting it.)

RE: Marty Gray, Dependent spouse of Dale Gray
Your Insurance ID Number: (Usually the spouse's Social Security Number)
Your Policy Number: (from spouse's insurance ID card)
Reimbursement of Payments Made

Dear Claims Person:

I am insured under the above health insurance policy as a dependent of employee, Dale Gray.

I am also insured under my employer's group health insurance. My employer is Dax Manufacturing Co., Inc. My coverage is an HMO policy through HMO Mutual of Azusa. The group policy number is xxxxx-xxx and my insurance ID with Mutual of Azusa is XXX-XX-XXXX.

It is my understanding that HMO Mutual which covers me as an employee is primary to your company which is secondary under the Coordination of Benefits rules.

I pay a co-pay of $10.00 per visit.

I am requesting that you reimburse me for my co-pays from the savings you realize by being the Secondary carrier. Attached are copies of receipts for ten co-payments I made which total $100. Please mail the check to me as follows:

Dale Gray
XXXXXXXXXXXX
XXXXXXX, XX XXXXX-XXXX

If you need more information, please let me know or request it from Dr. No directly. Thank you for your prompt attention to this request.

Very truly yours,

A PPO will determine what it will pay based on whether you are treated in or out of network. If you are treated by a doctor who is part of the PPO network, and you only pay a co-pay, the other carrier will only reimburse the co-pay and follow the steps for when one or both plans require a co-pay.

If, however, you use a doctor that is out of the PPO's network, or if using a network provider reduces your co-insurance percentage, then you should obtain a claim form and file a claim as instructed above under when both plans require filing a claims form.

If both of your carriers are HMO's and each only requires a co-pay:

• Keep in mind that your treatment must come from a doctor who is part of the primary carrier's network in order to be treated for just the co-pay. The doctor must also be a part of the secondary carrier's network to get reimbursed by the Secondary carrier for the co-pay.
• If you see the doctor regularly, you may want to accumulate several co-pays and request reimbursement for them every few months rather than one at a time.

To request reimbursement from the secondary carrier for the co-pays:

• Ask your doctor to bill the non-co-pay carrier (the secondary carrier if both plans require co-pays and treatment is delivered by a doctor that is in both networks), or
• Pay the doctor the co-pay, get a written receipt for the copay and file for reimbursement yourself. Then:
• Submit a claim form
• Include a copy of the receipt for having paid the co-pay
• Attach a cover letter, see sample below.

SAMPLE LETTER REQUESTING REIMBURSEMENT OF CO-PA

Date

(Name of Insurance Company)
Claims Office
(Address: You can get the mailing address
either from the claim form or by calling the
number on your insurance ID card and
requesting it.)

RE: Marty Gray, Dependent spouse of Dale Gray
Your Insurance ID Number: (Usually the spouse's Social Security Number)
Your Policy Number: (from spouse's insurance ID card)
Reimbursement of Payments Made

Dear Claims Person:

I am insured under the above health insurance policy as a dependent of employee, Dale Gray.

I am also insured under my employer's group health insurance. My employer is Dax Manufacturing Co., Inc. My coverage is an HMO policy through HMO Mutual of Azusa. The group policy number is xxxxx-xxx and my insurance ID with Mutual of Azusa is XXX-XX-XXXX.

It is my understanding that HMO Mutual which covers me as an employee is primary to your company which is secondary under the Coordination of Benefits rules.

I pay a co-pay of $10.00 per visit.

I am requesting that you reimburse me for my co-pays from the savings you realize by being the Secondary carrier. Attached are copies of receipts for ten co-payments I made which total $100. Please mail the check to me as follows:

Dale Gray
XXXXXXXXXXXX
XXXXXXX, XX XXXXX-XXXX

If you need more information, please let me know or request it from Dr. No directly. Thank you for your prompt attention to this request.

Very truly yours,

Y(S):>

If there are three plans, the Coordination of Benefits rules are thrown into overdrive.

Rather than try to guess at a difficult situation, ask your health care providers to send a copy of each medical bill to all three companies. Let them duke it out.