What is the difference between primary and secondary coverage?

Note: The below information refers only to a ClaimLinx Simple Option Solution plan. There are other types of secondary coverage that are similar, but can vary in detail.

The key to a ClaimLinx SOS plan is the combination of both primary and secondary coverage. It makes the plan more affordable for a business without sacrificing benefits, such as raising deductibles or copays.

In order to use these benefits, it’s important to understand the difference between primary and secondary coverage.

Primary Coverage — Also referred to as your Primary Carrier, this is the coverage from a major medical insurance company. Examples are Anthem, Humana, Cigna, Blue Cross Blue Shield, National General, Harvard Pilgrim and many more.

Members should refer to the primary carrier for their provider network and any coverage limitations. Issues with pre-authorization or required referrals all must be dealt with the primary insurance carrier.

Essentially, the primary coverage is the initial gatekeeper; all services must be approved and/or covered as a part of this plan before a member can receive any additional benefits from their secondary coverage.

Secondary Coverage — The Medical Expense Reimbursement Plan set up for the company that includes additional benefits (copays and/or lower deductible).  This plan is self-funded by the company, but is administered by ClaimLinx.

This means claims are processed first by the primary carrier and then are processed by ClaimLinx for any additional benefit. Click here to see the full process. Claims are processed within 10-15 business days of their receipt, though any missing or pending information can cause delays.

Members can view an Explanation of Benefits (EOB) for their claim on the member portal once the claim has been processed.

For secondary coverage, ClaimLinx follows all coverage or network decisions made by the primary carrier. For example, if a service is denied by the primary carrier, it will also be denied for secondary coverage with ClaimLinx. The same is true for if a provider is billed as in-network or out-of-network.

That is why we encourage all of our members to verify with their primary carrier that a service or procedure is covered before going to the provider.

Click here to see how to file a medical claim if your provider is not familiar with filing for secondary coverage. Contact the claims department with questions about the process or a specific claim at help@claimlinx.com.


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