When the Plan is the Secondary Carrier
- Participating Physician Groups (PPG)
(does not apply to HSP)
When the plan is the secondary carrier, the participating provider is entitled to receive payment from the primary carrier for services provided directly to the member.
The participating provider should obtain the signature of the member who is the policyholder with the other carrier on a standard Assignment of Benefits form.
The participating provider should also obtain from the member any claim form the other carrier might require.
Upon receiving an adjudication decision from the primary carrier, the participating provider submits a secondary claim to the plan with an attachment of the primary carrier's Explanation of Benefits (EOB). When the participating provider expects to receive reimbursement from the plan amounting to more than any required copayment, do not collect a copayment.
If, after both carriers have reimbursed the participating provider, the provider has not received reimbursement equal to or greater than the amount that is due under the provider's Provider Participation Agreement (PPA), the member can be billed for the required copayment provided the total reimbursement from all sources is no greater than what is due under the provider's PPA.
When the primary carrier is another HMO and the member is enrolled with two different participating providers (one with the primary carrier and one with the plan), the member may receive services through either participating provider. The participating provider cannot deny services based on the plan's status as the secondary carrier.