2 Insurance Companies, had a baby... so confused.

[Piecey]

I have insurance through my University.
In April DH accepted a job that made him eligible for benefits. We enrolled in a family plan health insurance program.
This new insurance pays maternity care at 100% and covers all members of his family instantaneously.
The college insurance is still my primary, DH's is my secondary.

The hospital where I delivered got them switched. I realized this when I started receiving letters from DH's insurance asking for an EOB from mine. I called the hospital and corrected it, but... DH's insurance had already received and paid the bill for DS's care. They paid 100% on 6/23/09. No letter asking for an EOB or anything like that.
Today I noticed on the website for my college insurance that the same claim was submitted to them as well. I called and it was submitted 7/12/09.
I advised them the claim was already paid in full by DH's insurance.

The lady told me that all she could do was put on the claim that I wanted it refused. I told her I didn't fully understand how insurance worked and that isn't what I wanted (it didn't sound like something I should do anyway!), I just wanted them to be aware that the claim had already been paid in full.
She told me that DS is covered under my policy automatically for 30 days. I told her I knew that but the other insurance was aware that I had primary coverage and they still paid it in full. She just kept repeating that DS is covered under my plan and unless I refused the claim they would process it and pay out their benefit.
I asked her how I was supposed to know which would be primary for DS- my primary plan or DH's plan in which DS was automatically covered under as a member at birth. She just kept repeating that she was going to mark that I wanted the claim rejected.

So my question is, anyone have any idea what I'm in for? She kept getting mad at me because the other company paid and DS is covered under my policy for 30 days and they had to pay their benefit still, etc.

I have a feeling this is going to give me several headaches.
Should I go back to the pediatrician/the obstetrician/etc. and have them bill my insurance, too? I've already told them all DS only has DH's insurance.

 

[rainy~daze]

whose birthday comes first in the year, you or your spouse? if yours is, then your policy was primary for the 1st 30 days. if his, then his is primary and has already paid, so there would be nothing left for secondary to pick up, unless you have remaining out of pocket costs, copay deductible, etc.

 

[INDISMOM]

I am going off memory here, because it has been awhile since DH and I have both had coverage --so if I am wrong someone can set me straight!

I think primary insurance for the kids depends on whose birthday comes first -- the mother's or the father's birthday.

So, if your DH's birthday is first your baby's primary insurance would be his, if yours is first then primary insurance is yours.

I would check back with who the bill is from (doctor, hospital, etc) and ask them to check their records because you show that the bill was paid in full on 6/23, but another claim was submitted on 7/12 to the other insurance company.

 

[phyllis1966]

whose birthday comes first in the year, you or your spouse? if yours is, then your policy was primary for the 1st 30 days. if his, then his is primary and has already paid, so there would be nothing left for secondary to pick up, unless you have remaining out of pocket costs, copay deductible, etc.

The above info is correct - the "birthday rule" determines which policy is truly primary. If your DH's policy is secondary, I can't imagine that they'd pay without asking for Coordination of Benefits info from you (your policy info).

 

[Normangirls]

DS only has the coverage yousign up for, and pay for.

The "30 days" just refers to the time you have to get him enrolled in whatever coverage you want him to have. That is, if he is going on DH's insurance, you have a 30-day grace period (starting the day DS was born) to get the paperwork done to sign him up (you husband would do this at his work).

If you do not want him covered on YOUR insurance, and never sign him up, the 30-day thing is irrelevant. He does not have 30 days of coverage on your insurance unless you sign him up (which you obviously don't want to do, since DH's coverage sounds great).

Your coverage (on you) is a different story. Like you stated, your insurance is your primary coverage. That insurance company MUST process your claims before your secondary coverage will process them. It sounds like DH's insurance company does not understand they are secondary, so they went ahead and paid. They need to be notified, and your insurance needs to process your claims.

The woman you talked to (at your insurance carrier) is a first-class idiot. Let's hope she didn't mess everything up even more.

Call your Human Resources department, and DH's Human Resources department, to help get it straightened out before someone really screws this up and you get stuck trying to fix it.

Oh, and good luck (you're gonna need it).

And this was recently? So CONGRATULATIONS on the baby!

 

[Piecey]

Okay, DH's birthday is in January, mine is in April so sounds like his insurance company knew they'd be primary and paid it. (They know my DOB so that would make sense)

Like I said, they knocked all the claims from the hospital for me back and wanted an EOB from my insurance for MY stuff, but paid for DS's stay in full (no deductible, which baffled me a bit, but I won't complain!)...

So sounds like DH's insurance actually DOES know what is going on. They know they're secondary for me, since they kicked all the hospital's claims back wanting an EOB from my insurance-- and that they know they're primary for DS (since DH is January/ I'm April) and they went ahead and paid their benefit, which was 100%.

Thanks everybody, you would think the lady at my insurance company would have known about the birthday rule?!

(Thanks for the congrats on the baby, He's 6wks today! )

 

[pyrxtc]

I never paid anything to have any of my kids, no deductable or co-pays. Insurance covered it all.

 

[boltfans]

That birthday rule applies to you too, so I'm not sure why your husband's insurance wanted EOBs for your care. Not only should both insurance companies know this, but the hospital should as well (and any drs, etc.) Ours always ask for both birthdays to be sure they are submitting the claims properly.

 

[Piecey]

That birthday rule applies to you too, so I'm not sure why your husband's insurance wanted EOBs for your care. Not only should both insurance companies know this, but the hospital should as well (and any drs, etc.) Ours always ask for both birthdays to be sure they are submitting the claims properly.

It's because I am the policy holder for the student insurance. That is how it was explained to me anyway, when I was trying to figure out who was primary. They said my insurance will always be primary for me.
If DH had been the policyholder for both they said it would be the policy that had become effective the earliest-- so I'd never heard of the birthday rule before.

I don't really care that DH's is kicking stuff back to mine-- DH's covers 100% so whatever my insurance company doesn't, they will. No skin off my back if it just takes a bit longer for the hospital to get their money.
My insurance company has been paying MY claims, so they must agree that they are primary as well.

 

[Nancy]

That birthday rule applies to you too, so I'm not sure why your husband's insurance wanted EOBs for your care. Not only should both insurance companies know this, but the hospital should as well (and any drs, etc.) Ours always ask for both birthdays to be sure they are submitting the claims properly.

No it doesn't. Since she is the employee and the subscriber on her plan it is primary for her no matter what. The kids go by the birthday rule.

As for the 30 day overage for newborns...that depends on the policy, some will have automatic coverage for the first 30 days, others don't so they only give the grace period. Usually what happens with those is claims get denied and have to e sent back one enrollment is updated.

Saying she can mark it that you are saying to reject the claim? Never heard of that. As far as I know it is by law that insurance has to process all claims that come in. I know that have to processed within 30 days of receiving them.

 

[Nancy]

It's because I am the policy holder for the student insurance. That is how it was explained to me anyway, when I was trying to figure out who was primary. They said my insurance will always be primary for me.
If DH had been the policyholder for both they said it would be the policy that had become effective the earliest-- so I'd never heard of the birthday rule before.

I don't really care that DH's is kicking stuff back to mine-- DH's covers 100% so whatever my insurance company doesn't, they will. No skin off my back if it just takes a bit longer for the hospital to get their money.
My insurance company has been paying MY claims, so they must agree that they are primary as well.

There is a lot that goes into processing when there is 2 insurances.


The way it would be done is they process the claim as if they were primary, so there will be an allowed amount. If the primary already paid the allowed amount or more than secondary picks up nothing...but if the primary payed less then that is where the secondary comes in. Then it would apply to however the benefits would normally (deductible, co insurance or paying the balance for 100 %).

Example, claim comes in with a charge of 1000.00, the allowed amount is 500.00. Primary insurance paid 500.00..then secondary pays nothing. BUT if the allowed is 800.00 and primary only paid 500.00 the secondary will process the difference as per plan benefits.

 

[novajeanjellybean]

Just wanted to say that your son is adorable!!! Congratulations!!!!