| Course | HCA 110 Insurance and Healthcare Reimbursement |
|---|---|
| Module | Module 5 |
| Paper type | Coordination of benefits paper |
| Length | About 1,036 words, 6 pages |
| Format | APA 7 student paper |
| School | Aspen University |
| Program | Health Care Administration |
| Updated | September 2026 |
Free sample paper for HCA 110 Module 5
Which Plan Pays First? Coordination of Benefits and the Secondary Claim
Student Name
Health Care Administration Program, Aspen University
HCA 110: Insurance and Healthcare Reimbursement
Instructor Name
Month Day, Year
Which Plan Pays First? Coordination of Benefits and the Secondary Claim
When a patient has more than one health plan, the plans must decide which pays first so that together they do not pay more than the cost of care. This process, coordination of benefits, affects millions of patients, including children covered by two parents, spouses with their own employer plans and older adults who keep working after joining Medicare. Billing the wrong plan first leads to denials and delays. This paper works through two composite cases and explains how the secondary claim is filed.
Why Coordination Exists
Coordination of benefits prevents duplicate payment. The primary plan pays first according to its benefits, and the secondary plan then considers the remaining balance under its own rules. The patient may owe little or nothing after both plans pay, but never less than the secondary plan's rules allow. For the billing office, the task is to identify every plan, determine the order and send each claim to the right payer with the right information.
Case One: A Child With Two Plans
Lily, a composite 7-year-old, is covered through both her mother's employer plan and her father's. Her parents are married and live together. Most commercial plans settle this with the birthday rule: whichever parent's birthday comes first between January and December has the primary plan, and the year of birth does not matter. Lily's mother was born on March 14 and her father on August 2, so the mother's plan is primary. If the parents were divorced, a court order or custody rules would usually decide instead.
Case Two: Working Past 65
Mr. D., a composite 67-year-old engineer, still works full time and has group health coverage through his employer of 300 people. He also enrolled in Medicare Part B. Under Medicare Secondary Payer rules, a group health plan of an employer with 20 or more employees is primary for a working person aged 65 or older who has coverage based on current employment, and Medicare is secondary (Centers for Medicare & Medicaid Services, 2024). If Mr. D. retires and keeps retiree coverage, Medicare becomes primary.
Order of Benefits
The table summarizes the rules applied to these and similar situations.
| Situation | Primary | Secondary |
|---|---|---|
| Patient's own employer plan and spouse's plan | Patient's own plan | Spouse's plan |
| Child of married parents with two plans | Plan of parent with earlier birthday | Other parent's plan |
| Age 65+, working, employer 20+ employees | Employer group plan | Medicare |
| Age 65+, retired with retiree plan | Medicare | Retiree plan |
| Medicare and Medicaid | Medicare | Medicaid |
| Work injury | Workers' compensation | Health plan only if claim denied |
Collecting the Information
Coordination starts at registration. Staff should ask every patient at every visit whether they have other coverage, including coverage through a spouse or parent and any accident or work injury claim. Medicare requires providers to collect Medicare Secondary Payer information from beneficiaries, usually through a questionnaire at registration. Both insurance cards are scanned, and the subscriber for each plan is recorded with date of birth and relationship.
Filing the Primary Claim
The primary claim goes first, showing the other coverage in the claim's other insurance fields so the primary payer knows a secondary plan exists. For Mr. D.'s office visit with an allowed amount of $180, his employer plan paid $140 and assigned $40 to his coinsurance. The primary payer's remittance advice shows the allowed amount, the payment and the patient's responsibility with the adjustment codes used.
Filing the Secondary Claim
The secondary claim carries the same services and codes plus the primary payer's adjudication: its paid amount and the adjustments, such as the coinsurance amount assigned to the patient. Electronic secondary claims include these details at the claim and line level; paper claims attach the primary remittance advice. Adjustment codes follow the standard code list, for example group code PR with reason code 2 for coinsurance (X12, n.d.). Medicare, as secondary, then considered the $40 balance and paid its share under its own rules.
How COB Goes Wrong
Common errors include billing Medicare first for a working beneficiary with employer coverage, not knowing about a spouse's plan, and sending the secondary claim without the primary payer's details. The secondary payer then denies the claim, often with an adjustment reason code stating that the care may be covered by another payer. Denials and complex payer rules are costly: remittance data from 2013 to 2015 showed denial rates varying widely by payer type, and the authors estimated billions of dollars in challenged physician revenue each year (Gottlieb et al., 2018).
When Coverage Changes
Coordination is not set once. A spouse changes jobs, a parent loses coverage or a patient retires, and the order changes. Plans also send questionnaires to members to update other-coverage information, and claims can be held until members respond. The billing office should update coverage at each visit and tell patients promptly when a plan is waiting for their answer.
Patient Communication
Patients often believe that having two plans means they pay nothing. Staff should explain that the secondary plan pays under its own rules and that a balance may remain. When a claim is held because a plan needs the patient's other-coverage information, a quick call to the patient usually resolves it faster than repeated calls to the plan.
Medicaid as Payer of Last Resort
Medicaid is generally the payer of last resort. When a patient has Medicaid and any other coverage, including Medicare or an employer plan, the other coverage pays first and Medicaid considers what remains. For a patient with both Medicare and Medicaid, the Medicare claim is often forwarded automatically to Medicaid through a crossover arrangement, but the billing office should confirm that the crossover occurred. Billing Medicaid first for a patient with other coverage leads to a denial and, if paid in error, to a later recovery.
Conclusion
Coordination of benefits decides which plan pays first and makes sure the second plan has what it needs to pay its share. The birthday rule settled Lily's case, and Medicare Secondary Payer rules settled Mr. D.'s. Asking about other coverage at every visit, filing the primary claim first and passing the primary payer's details to the secondary plan prevent the denials that coordination errors cause.
References
Centers for Medicare & Medicaid Services. (2024). Medicare secondary payer. https://www.cms.gov/medicare/coordination-benefits-recovery/overview/medicare-secondary-payer
Gottlieb, J. D., Shapiro, A. H., & Dunn, A. (2018). The complexity of billing and paying for physician care. Health Affairs, 37(4), 619-626. https://doi.org/10.1377/hlthaff.2017.1325
X12. (n.d.). Claim adjustment reason codes. https://x12.org/codes/claim-adjustment-reason-codes
Reading the HCA 110 Module 5 assignment instructions
Because Aspen's HCA 110 description names secondary claims and the module prompt is held in the classroom, coordination of benefits became the topic of this example. Assignments on this topic usually ask you to determine which plan is primary in given cases, explain the rules you used and describe how the secondary claim is filed. Some ask about Medicare Secondary Payer rules or Medicaid specifically. Read each case in your prompt carefully, since details such as marital status, employer size or retirement change the answer. Show your reasoning for each decision rather than only the result, and cite the rule you applied. Keep each case in its own section so the grader can follow your decision without searching.
How this HCA 110 Module 5 example is built
The example covers about 1,040 words under thirteen headings and includes an order-of-benefits table. After explaining why coordination exists, it works Lily's case with her parents' birth dates and Mr. D.'s case with his employer's size. The table extends the rules to spouses, retirees, dual Medicare and Medicaid coverage and work injuries. Sections then explain collecting coverage at registration, filing the primary claim and filing the secondary claim with the primary payer's figures. Common errors, coverage changes, patient communication and Medicaid as payer of last resort come before the conclusion. Margin notes explain why each case is worked with real numbers. The conclusion restates both decisions and the rule behind each one.
HCA 110 Module 5 rubric: what earns full marks
Instructors marking coordination papers generally look for correct primary and secondary decisions, explained reasoning, understanding of the secondary claim and correct sources. Each decision here is correct and names its rule: the birthday rule and the employer-size rule for Medicare. The secondary claim section shows the amounts and adjustment code carried forward. CMS pages, the X12 list and one journal study supply the references, formatted in APA. Extra credit tends to go to papers that treat coordination as ongoing, since coverage changes, and that explain to patients why a balance may remain. This paper does both in its closing sections. Clear case-by-case headings also help, since graders can match each decision to the rule applied.
HCA 110 Module 5 help from the desk
The most frequent error is assuming Medicare is always primary after 65. Check employment status and employer size. Students also apply the birthday rule using the parents' ages instead of the month and day. Another gap is describing the secondary claim without the primary payer's payment details, which is exactly what the secondary plan needs. For divorced parents, look for a court order before applying the birthday rule. If your cases are complicated, our tutors can work through them with you and check each decision against the rules. State the order of benefits in a single sentence for each case before explaining it, and cite the rule each time.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
More HCA 110 and Health Care Administration sample papers
- HCA 110 Module 1: Insurance Types and the Revenue Cycle
- HCA 110 Module 2: Verifying Benefits and Estimating Cost
- HCA 110 Module 3: Reviewing the Record to Support Codes
- HCA 110 Module 4: Completing a Clean Claim
- HCA 110 Module 6: Posting Payments and Reading a Remittance
- HCA 110 Module 7: Analyzing Denied Claims
- HCA 110 Module 8: Writing an Appeal for a Denied Claim
- HCA 315 Module 6: The Medical Record as a Legal Document
- HCA 320 Module 3: Health Policy Process Paper
- HCA 125 Module 3: Financial Statement Analysis
- HCA 310 Module 2: Registering a Patient and Building the Record
HCA 110 Module 5 questions, answered
What does HCA 110 Module 5 usually ask for?
Aspen's HCA 110 description includes secondary claims, so a coordination of benefits exercise is a typical assignment. Check your classroom for the prompt.
What is the birthday rule?
When married parents both cover a child, the parent born earlier in the year by month and day usually holds the primary plan.
Is Medicare always primary after 65?
No. For people who are still working with group coverage from an employer of 20 or more employees, the employer plan is usually primary and Medicare secondary.
Where can I find a free HCA 110 Module 5 sample paper?
The coordination of benefits paper above, with both worked cases and the order-of-benefits table, is fully readable here at no charge. It is the fifth HCA 110 sample.
Why is Medicaid the payer of last resort in HCA 110 Module 5?
Medicaid pays only after all other coverage has paid, so any other plan, including Medicare or an employer plan, is billed first.