In some instances, a patient may have coverage with two insurance companies, this is referred to as “dual coverage.” These coverages do not stack, rather the secondary insurance is supplemental to the primary. Here are some general guidelines for a patient with dual coverage.
Determining the Primary and Secondary:
The first step is determining which plan is primary and which is secondary. Typically, an enrollee’s plan is primary while a dependent’s plan is secondary. For children, the general rule for primary is whichever parent’s birth month then day is first (not year).
For example, you may have a female patient whose employer has selected Cigna for their dental plan. Her husband’s employer utilizes Delta Dental. The woman’s primary would be Cigna and her secondary would be Delta. The husband’s coverage would be the opposite. For children, if the mother’s birth month is first, her insurance is primary. For example, if the mother’s birthday is in March and the father’s is in December, the mother’s plan is primary, regardless of the year the parent was born. If the parents are divorced, a court ruling may dictate whose insurance is primary. If one of the parents has a discount plan, rather than a PPO plan, this is not dual coverage.
Every plan is different and could have exclusions so we recommend always calling both insurance companies to verify.
Billing:
Submit the dental claim to the primary carrier first. After you receive notice the claim has been accepted and paid, submit the claim to the secondary carrier with payment receipt from the primary insurance company. Secondary carrier reimbursement will depend on the coordination of benefits.
Coordination of Benefits:
There are two types of coordination of benefits a plan may offer: Traditional and Non-Duplication. A Traditional coordination would be when the expenses will be covered entirely for the patient’s services between the two plans. The second coordination is called Non-Duplication. This means that if the primary pays, the secondary will consider paying but will never pay more than they would have if they were the Primary. Non-Duplication can be much harder to quote to patients so we recommend letting the patient know the quote may not be accurate since it is dependent on how each plan ends up paying.
What about being in-network or not?
Whether you are in-network with the primary, secondary, or both, you must always accept the lowest discounted PPO rate. If the secondary is the lower fee schedule, you may need to make an additional adjustment after both insurance companies have paid if your software system only makes an adjustment for the primary insurance.
References:
- Delta Dental Website – https://www.deltadental.com/Public/FAQ/dentistFAQ.jsp
- Dental Insurance Navigator – http://dentalinsurancenavigator.com/training-center/#video10 (Secondary Insurance Video)
- Unitas Dental Clinical Department
If you have a question about a patient or situation, please reach out to the insurance carrier for clarification.