Denied because the insurer says you have other insurance

Why was my claim denied for other insurance?

You are not alone. When you have more than one plan, the plans have to settle on an order of payment. If a plan thinks another plan should pay first, or its records about your other coverage are out of date, it may deny or hold the claim until the order is sorted out.

The denial letter or the explanation of benefits usually says something like other coverage or coordination of benefits. That wording is a clue that the problem may be the order of payment, not whether the care is covered. Read the whole letter, because it may list other reasons too.

Which insurance pays first, mine or my spouse's?

The Connecticut Office of the Healthcare Advocate explains that your own employer's plan is generally primary for you, and your spouse's employer's plan is primary for your spouse. The plan that covers you as a dependent through a spouse is then usually secondary.

The primary plan pays your claim as if there were no other insurance. The secondary plan may then pay some of what the primary plan did not cover. These are general rules for employer health plans described by one state office. Medicare, Medicaid, COBRA, marketplace, and dental plans can follow different rules, and your own plan documents have the final word, so read them or ask each insurer.

Which parent's insurance pays first for my child?

For a child covered under both parents' plans, the Connecticut Office of the Healthcare Advocate describes the birthday rule: the plan of the parent whose birthday, month and day only, falls earlier in the calendar year is typically primary. If both parents share a birthday, the plan that has covered a parent longer is primary.

The same page notes that different rules may apply to children of divorced or separated parents. If that is your situation, or if your plans are not both employer plans, ask both insurers which rule they are using and write down what they say.

How do I fix my coverage information with both insurers?

The goal is to get both insurers holding the same, correct facts about who is covered and which plan is first.

• Step 1: Gather your cards and the denial. Have both insurance cards, the denial letter or explanation of benefits, and the date of the service in front of you.
• Step 2: Call the plan that denied it. Use the member services number on the back of the card. Ask what other coverage they have on file for you and ask them to tell you exactly what they need from you to update it.
• Step 3: Call the other plan. Confirm it lists you as covered and ask whether it considers itself primary or secondary for you or your child. Ask for the answer in writing if you can.
• Step 4: Ask for the claim to be sent again. Once both records match, ask the plan that denied the claim to reprocess it, and ask your provider to send it to the plan that should pay first. Keep notes of the date, the person, and what was said. Your denial letter explains how to appeal and by when, so check that date in case the records take time to fix.

What if I have Medicare and other insurance?

Medicare.gov says the primary payer pays up to the limits of its coverage, then sends the rest of the balance to the secondary payer. If the secondary payer does not cover the remaining balance, you may be responsible for the rest, so it is worth getting the order right.

Medicare.gov says to tell your doctor and other health care providers about any changes in your insurance or coverage when you get care. For questions about who pays first or about coverage changes, it lists the Benefits Coordination and Recovery Center at 1-855-798-2627 (TTY 1-855-797-2627).

Can you look at my denial letter?

Yes. Text a photo of your denial letter to (213) 606-6303. We read it and reply with where it breaks. It is free, with no account and no form.

We are not lawyers and this is not legal or medical advice. We help you understand the letter so your next call or appeal is easier.

Your checklist

• Both insurance cards, front and back
• The denial letter or explanation of benefits
• Date of service and provider name
• Name of the policyholder on each plan
• Who called, when, and what they said (notes)
• Written confirmation of which plan is primary
• Ask the denying plan to reprocess the claim
• The appeal deadline printed on your denial letter

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• Your claim was denied as "not covered" or excluded. Is that the end?
• Your claim was denied for being filed too late. Here is what that means and what you can do.
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.