NHA Certified Clinical Medical Assistant (CCMA)Administrative TasksHard
A medical assistant is processing a claim for a patient who has both Medicare and a supplemental insurance policy. Which of the following is the correct order for submitting the claim?
- ASubmit only to Medicare, as it is the primary payer.
- BSubmit to both insurances simultaneously.
- CSubmit to Medicare first, then to the supplemental insurance.
- DSubmit to supplemental insurance first, then Medicare.
Show answer & explanationAnswer & explanation
Correct answer: C. Submit to Medicare first, then to the supplemental insurance.
When a patient has Medicare and a supplemental (Medigap) policy, Medicare is always the primary payer. The claim must first be submitted to Medicare. Once Medicare has processed the claim and paid its portion, the remaining balance is then forwarded to the supplemental insurance policy for secondary coverage.
Why the other options are wrong
- A. While Medicare is primary, supplemental insurance provides additional coverage for out-of-pocket costs, so it must also be billed.
- B. Claims are typically processed sequentially, not simultaneously, to establish primary and secondary payer responsibilities.
- D. Submitting to supplemental insurance first is incorrect; Medicare is always primary when a Medigap policy is involved.
Coordination of Benefits (COB) - Medicare
Coordination of Benefits (COB) rules determine which insurance plan pays first when a patient has more than one policy. For Medicare and supplemental plans, Medicare is always primary.
- Medicare is always the primary payer when a patient has a Medigap (supplemental) policy.
- The primary payer processes the claim first and pays its share.
- The secondary payer (supplemental insurance) then covers remaining eligible costs.
Memory trick: Primary always 'PAYS FIRST,' then secondary 'SUPPORTS' the rest.