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Secondary claims

When a client carries two coverages, the secondary payer wants to know what the primary did before it pays its share. Secondary claims package exactly that — the primary's payment and adjustments ride along as coordination-of-benefits data.

In this guide, we'll cover:

Before you start​

The client needs a Secondary coverage on file (added like any coverage on their Payment & Insurance tab, with Type = Secondary). It can be added after the primary claim was filed — the button below reads the client's current coverages. File and finish the primary claim first — a secondary claim filed before the primary adjudicates will bounce.

Creating a secondary claim​

  1. Open the primary claim's detail page. Once the client has secondary coverage and the claim has progressed (submitted, accepted, paid, denied, applied to deductible, or marked as filed externally), a Create Secondary Claim button appears in the header beside the claim's other actions. A primary you filed on the payer's portal or on paper works too: create it here, mark it Filed Externally, and the button appears.
  2. The secondary claim is created at once and opens on its own CMS-1500, labelled Secondary claim, with a link back to the primary. Two parts of the form belong to secondary claims only, and both are filled for you when the primary's ERA is in the system:
    • Box 8: Other payer COB — what the primary paid, the remaining patient responsibility, the primary's claim control number, and the adjudication date.
    • Under each service line, a COB row (Paid $, Remaining $, Quantity, Adjudication date) and an Adjustments row with the payer's group and reason codes and amounts (for example CO-45 or PR-3). Remaining $ on the line stays blank unless a payer asks for it per line; Box 8 carries the total. Quantity is the paid units, which default to the line's billed units, and the date defaults to Box 8's. If the primary's payment was entered by hand, those figures come from that payment with the usual reason codes; if there is no payment on record yet, the boxes open blank in edit mode.
  3. Check the figures against the primary's EOB. The form opens ready to edit: to change any of them, type in Box 8 or the rows under the line, add or remove adjustments, and Save.
  4. Click Submit to Payer, or file it externally like any other claim. The CMS-1500 also carries the other-insured details (Boxes 9 and 11d "YES") automatically. Box 29 is left blank on a secondary claim; the primary's payment travels in Box 8 and the COB rows, and putting it in Box 29 as well is a common cause of secondary rejections.

On the Claims tab, the Primary claims / Secondary claims dropdown beside the payer filter shows just your secondaries, and each one carries a Secondary badge.

Common scenarios​

Payers read a secondary claim from the group and reason codes on each line, so the same three patterns cover most filings. In every case the primary's Paid $ plus every adjustment amount must add up to the line's charge; the clearinghouse checks this and rejects a claim that does not balance.

The secondary covers the client's copay or coinsurance. Fee $100, primary allowed and paid $65, wrote off $10, and the $25 copay goes to the secondary. Box 8: Paid 65, Remaining 25. Line 1a: Paid 65. Adjustments: CO 45 for 10 (the write-off) and PR 3 for 25 (copay; use PR 2 for coinsurance). 65 + 10 + 25 = 100.

The secondary covers a deductible. Fee $100, deductible not met, primary paid $0, wrote off $25, and $75 is the client's responsibility. Box 8: Paid 0, Remaining 75. Line 1a: Paid 0. Adjustments: CO 45 for 25 and PR 1 for 75 (deductible). 0 + 25 + 75 = 100.

The primary denied the claim as out of network. The full fee can go to the secondary. Fee $100, primary paid $0. Box 8: Paid 0, Remaining 100. Line 1a: Paid 0. Adjustments: PR 242 for 100 (services not provided by network providers). 0 + 100 = 100.

Payers can have their own rules on top of these. If a secondary claim is rejected after you have used the codes above, the rejection message names what the payer wants changed.

Tips​

  • Wait for the primary ERA when you can — auto-population beats hand-copying an EOB, and the numbers are the payer's own.
  • The secondary claim starts from the primary's services and diagnoses, so corrections belong on the primary first; recreate the secondary after fixing.
  • Track it on the Claims tab like any claim — same statuses, same fixing tools.