Understanding Multiple Carrier TPR Codes in Medical Billing: Primary & Secondary Insurance Denials & Payments
What are TPR Codes? Navigating Multi-Carrier Claims
In the complex world of medical billing, understanding Transaction Processing Reason (TPR) codes is paramount, especially when dealing with multiple insurance carriers. TPR codes, often seen on Explanation of Benefits (EOB) forms, provide crucial insights into the payment status or denial reasons for medical claims involving both primary and secondary insurance. These secondary payer remark codes help billing specialists decipher why a claim was paid, denied, or adjusted, enabling efficient revenue cycle management and prompt resolution of outstanding balances. Effectively interpreting these codes, which can sometimes be considered a form of claim adjustment reason codes, is essential for healthcare providers to streamline their billing processes, reduce rejections, and maximize reimbursements.
Coordination of Benefits (COB) Explained
Understanding TPR codes goes hand-in-hand with grasping the concept of Coordination of Benefits (COB). COB is the process by which health insurance companies determine their respective financial responsibilities when an individual is covered by more than one health benefit plan. It ensures that a patient does not receive duplicate payments for the same service from multiple insurers. Typically, one plan is designated as primary, paying its benefits first, and the other plan(s) act as secondary, paying for services only after the primary plan has processed the claim. The secondary plan will then consider the remaining balance, taking into account any deductibles, co-pays, or non-covered services. The rules for COB can be intricate and vary by payer, making the interpretation of these coordination of benefits codes critical in multi-carrier claim processing. For comprehensive guidance on COB, refer to official resources such as the CMS Coordination of Benefits (COB) Process.
Common TPR Codes and Their Meanings in Medical Billing
Here’s a detailed breakdown of frequently encountered TPR codes, categorized for clarity, along with their implications and recommended next steps for your billing team.
Payment Status Codes
- MP: Primary insurance paid – secondary paid
This is the ideal scenario where both the primary and secondary insurance carriers have processed and paid their respective portions of the claim, aligning with their Coordination of Benefits (COB) rules. - PU: Primary insurance under deductible – secondary paid
Indicates that the primary insurance applied the service towards the patient’s deductible, resulting in no payment from the primary. However, the secondary insurance has subsequently processed and paid its portion of the claim. Review the EOBs from both payers to ensure accurate deductible application and payment. - SP: Primary insurance paid – secondary payment went to patient
The primary insurer paid its share, but the secondary insurer mistakenly sent its payment directly to the patient rather than the provider. Your billing team should contact the patient to collect the payment or request that they forward the payment to the provider. - SH: Primary insurance paid – secondary payment went to policyholder
Similar to SP, but the secondary payment was sent to the policyholder (who may or may not be the patient). Follow up with the policyholder to retrieve the payment.
Deductible & Co-pay Related Codes
- SU: Primary insurance paid – secondary under deductible
The primary insurance has paid its portion, but the secondary insurance has applied the remaining balance to the patient’s deductible, meaning the patient is now responsible for this amount. Review the secondary EOB to confirm the deductible amount and prepare to bill the patient. - MU: Primary and secondary under deductible
Both the primary and secondary insurance carriers have applied the services towards the patient’s respective deductibles, resulting in no payment from either. The full claim amount, up to the deductible limit, is now the patient’s responsibility. Ensure accurate patient billing and follow up on payment.
Coverage & Eligibility Denials
- SS: Primary insurance paid – secondary service not covered
The primary insurer paid, but the secondary insurer denied the claim because the specific service is not covered under the patient’s secondary policy. Verify the patient’s secondary benefits for covered services. This may require discussing the non-covered service with the patient. - SC: Primary insurance paid – secondary patient not covered
Primary insurance paid, but the secondary insurer denied the claim due to the patient not being covered under that secondary policy for the date of service. This could indicate a lapse in coverage or incorrect policy information. Verify patient eligibility and coverage dates for the secondary plan. - ST: Primary insurance paid – secondary canceled/terminated
The primary insurer paid, but the secondary policy was canceled or terminated prior to the date of service. Verify the active coverage dates for all policies. The patient may be responsible for the secondary portion. - SL: Primary insurance paid – secondary lapsed or not in effect
Similar to ST, this code indicates that the secondary policy was not active or had lapsed at the time services were rendered. Confirm patient insurance details and inform the patient of their financial responsibility for the secondary portion. - MC: Service not covered by primary or secondary insurance
Neither the primary nor secondary insurance covered the service. This could be due to specific exclusions, lack of medical necessity, or experimental status. Review both EOBs for detailed denial reasons and inform the patient of their full financial responsibility.
Authorization & Information Denials
- SA: Primary insurance paid – secondary denied – service not authorized
The primary insurance paid, but the secondary insurer denied the claim because the service required prior authorization which was not obtained or was denied. Actionable Steps: Review patient’s secondary benefits and verify if prior authorization was required. If so, gather necessary documentation and initiate an appeal with the secondary payer, providing documentation of medical necessity or a retroactive authorization if possible. - SE: Primary insurance paid – secondary denied – service not considered emergency
Primary insurance paid, but the secondary insurer denied the claim stating the service was not an emergency, despite being submitted as such. This often occurs with emergency room visits. Actionable Steps: Review the clinical documentation for clear indications of emergency medical necessity. If justifiable, appeal the decision with supporting medical records. - SF: Primary insurance paid – secondary denied – service not provided by primary care provider/facility
The primary insurer paid, but the secondary insurer denied because the service was not rendered by an approved primary care provider or facility, typically indicating an out-of-network issue or a specific network requirement for secondary coverage. Actionable Steps: Verify the secondary plan’s network requirements. If the provider was out-of-network, inform the patient of their potential higher financial responsibility. An appeal may be possible if an in-network referral was required but not obtained, or if the situation warranted an out-of-network visit. - SM: Primary insurance paid – secondary denied – maximum benefits used for diagnosis/condition
The primary insurer paid, but the secondary insurer denied because the patient has reached their maximum benefit limit for the specific diagnosis or condition under that secondary plan. Actionable Steps: Inform the patient that their secondary benefits for this condition have been exhausted. Future services for this condition will likely be their full responsibility unless another payer is involved. - SI: Primary insurance paid – secondary denied – requested information not received from policyholder
Primary insurance paid, but the secondary insurer denied because information requested from the policyholder was not submitted. Actionable Steps: Contact the policyholder immediately to identify the missing information and assist them in submitting it to the secondary payer for reconsideration. - SR: Primary insurance paid – secondary denied – requested information not received from patient
Primary insurance paid, but the secondary insurer denied because information requested from the patient was not submitted. Actionable Steps: Contact the patient immediately to identify the missing information and assist them in submitting it to the secondary payer for reconsideration.
Other Scenarios
- MO: Other (if above codes do not apply, include detailed explanation of why there was no payment from insurances)
This is a catch-all code for situations not covered by the more specific TPR codes. When using MO, it is absolutely critical to provide a thorough and detailed explanation in the claim submission or appeal. Lack of a clear explanation will almost certainly lead to further delays or denials. Actionable Steps: Carefully document the specific reason for non-payment, referencing EOB details, payer communication, and relevant policy clauses. This explanation is key to proper claim resolution.
Disclaimer: Insurance codes, policies, and claim adjustment reason codes are dynamic and subject to frequent updates. Always consult the most current payer-specific guidelines, official industry resources, and the NUCC’s CMS-1500 form instructions for the most up-to-date and accurate information regarding medical billing practices and code interpretations. Understanding these **explanation of benefits (EOB) terms** is crucial for efficient claim processing.
