Policy: Clients with Private Insurance (Primary) and Medicaid (Secondary/Supplementary)

Purpose

To ensure proper coordination of benefits and compliance when billing private insurance first and Medicaid second.

Policy Overview

When a client has both private insurance and Medicaid, private insurance must always be billed first.

If the private insurance leaves a copay, coinsurance, or deductible, Medicaid may cover these remaining amounts, depending on the client’s eligibility and Medicaid coordination rules. Scope

This policy applies when a client has:

✅ Private insurance listed as primary

✅ Maryland Medicaid listed as secondary

✅ Does not apply to Medicare

Eligible primary plans include: CareFirst BCBS, Cigna, UnitedHealthcare (UHC)

Procedure

Step 1: Verify Both Coverages

1. Confirm through Carelon or the Maryland Medicaid portal that Medicaid is active as secondary coverage.

2. Confirm the primary insurance details (payer ID, plan type, copay, deductible, and coinsurance).

3. Document both active coverages in the client’s chart under Billing Notes.

Step 2: Inform the Client

Explain coverage to the client in simple terms:

“Since you have private insurance as your primary coverage and Medicaid as secondary, we’ll bill your primary insurance first. If there’s any remaining copay or balance, we may be able to submit it to Medicaid for possible coverage.”

Step 3: Insurance Setup & Authorization

1. Add Medicaid to the client’s insurance section. Tag Medicaid as Secondary under Priorty

2. Request an authorization in Carelon for therapy:

Service code: 90837

3. If the client is receiving medication management, include:

99205, 99213, 99214, 99215

Step 4: Billing Process

1. Submit the claim to the primary insurance first.

2. Wait for the Explanation of Benefits (EOB) showing what the primary paid and what remains as client responsibility.

3. If there’s a remaining copay, deductible, or coinsurance, submit a secondary claim to Medicaid with the EOB attached.

4. Medicaid may pay all or part of the balance, depending on the COB rules.

Step 4: Documentation

1. Add a billing note: “Client has private insurance primary and Medicaid secondary. Medicaid may cover remaining copay or coinsurance.”

2. Upload a copy of both insurance cards in the client’s billing settings in Therapy Notes.

Step 5: When Medicaid Does Not Cover the Balance

1. If Medicaid denies payment for the remaining copay or deductible:

2. The client is responsible for the balance as stated in their primary insurance plan.

3. Document the denial and notify the client before processing future claims.

Key Notes

Medicaid cannot be billed as primary when private insurance is active.

Do not collect copay from the client until the Medicaid secondary claim is processed.

Always verify coordination of benefits yearly or when the client reports insurance changes.