Wiki COB- Secondary denying claims Primary already applied to deductible

[ciarahertzog]

I have a current OB patient who has BCBS as primary and Aetna as secondary. She has been seen for multiple office visits [99211] above her routine maternity visits due to a complication of her pregnancy. Her BCBS insurance has applied each of these visits to her deductible. When sent on to Aetna they have been denied as included in the global maternity billing and Aetna states the patient's responsibility is zero. We are appealing this decision [as these visits should not be included in the global]. But if their decision stands, are we forced to take the write-off because we are contracted with them and eat the cost for the visits?

 

[Cavalier40]

That depends on if your contracted amount for 99211 for Aetna is higher than what is allowed for BCBS. For example if you bill $100 for 99211 and your BCBS contracted rate is $70 and your Aetna contracted rate is $65, Aetna will not pay unless their plan has a provision that secondary payment will cover primary deductible. (This can be asked upon verification) If the Aetna plan does not have that provision, then Aetna will assume the $70 of patient responsibility is collected and they will not pay beyond their contracted rate. If Aetna rate is higher, then they might only pay the difference between the BCBS allowed and the Aetna allowed.

So I guess your first step is to call benefits for Aetna and see if secondary payment covers primary deductible.