The purpose of Members having a secondary insurance payor is to reduce the Members’ costs associated with their responsibility after the primary insurance payor has adjudicated the claim. When Members have primary coverage through another payor, Community First will provide payment for covered services as the secondary payor only when there is Member responsibility after the primary insurer has paid.
Community First’s compensation to the Provider is limited to the difference between the amount paid by the primary payor and the lessor of the contracted rates set by the primary payor or the contracted rates set by the Provider’s contract with Community First, less applicable Copayments, Coinsurance, or Deductibles. Compensation to the Provider shall not exceed the Members’ responsibility, the primary payors contracted rates, or the TMHP Reimbursement Schedule for Medicaid Plans.
Frequently Asked Questions
What if the Provider is out-of-network with the primary insurance payor, will the secondary insurance cover the services?
No, Members must choose an in-network Provider with their primary insurance in order to bill the secondary payor to cover Member responsibility.
What if the services are denied as not being medically necessary by the primary payor, will the secondary insurance cover the services?
No, if the primary payor denies the services for medical necessity, the secondary would not cover as there are no covered services to pay.
What if the Provider is in-network, but the services are not a covered benefit, will the secondary insurance cover the services?
Yes, in the event the primary is in-network but does not have a specific service as a covered benefit, then the secondary payor becomes primary once we have received the Explanation of Payment detailing the denied services. The Provider will need to verify if an authorization is required, since this would make Community First the primary payor.
What if the primary insurance payor does not require a prior authorization and Community First does – will we have to get a prior authorization from Community First?
If Community First is secondary, and the primary payor pays, we do not require a prior authorization. If the primary payor denies based on exhausted benefits or non-covered services, then Community First would be considered the primary payor and would, therefore, require a prior authorization before services are rendered to the Member.
Next steps for Providers:
Providers should share this communication with their staff.
Community First Resources:
https://communityfirsthealthplans.com/provider-newsletter
https://communityfirsthealthplans.com/providers/
Contact:
Email ProviderRelations@cfhp.com or call 210-358-6294.
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