If a patient has coverage under a group plan and an individual plan, which is usually considered primary?

In situations where a patient holds both a group health insurance plan and an individual health insurance plan, the group plan is typically considered the primary insurance. This determination is largely based on the rules set forth by coordination of benefits (COB) regulations.

Group plans are generally established through an employer or an organization and are designed to provide coverage to employees and their dependents. Because these plans cover a larger pool of individuals, they are usually considered to have greater priority in terms of benefit coverage. This prioritization is intended to ensure that benefits can be effectively coordinated between plans, preventing issues that may arise from dual coverage.

In contrast, individual plans are purchased by the policyholder directly and may have different terms of coverage. While they can provide essential health benefits, they typically serve as a secondary source of coverage when a group plan is also in place. This ranking helps in establishing which plan's benefits should be utilized first when billing or seeking reimbursement for healthcare services, streamlining the payment process and reducing administrative complications.

Understanding this concept is essential for medical billing and coding professionals, as it affects how claims are processed and ensures that patients receive appropriate coverage while preventing overbilling or claim denials related to improper coordination of benefits.