Friday, May 13, 2016

List of Fields user for secondary cross over

Medicare Crossover for Other Blue Plan Members (CMS-1500)

Completing a claim correctly when a member has primary coverage with Medicare and secondary coverage (Medicare Supplement) from another Blue Plan will decrease your chance of receiving claim denials. The following instructions apply to items on the CMS-1500 form or its electronic counterpart that require specific Medicare Supplement information:

Item 9

• Enter the last name, first name and middle initial of the member if it is different from that shown in Item 2. Otherwise, you may enter the word “SAME”. If no Medigap benefits are assigned, leave blank.

Item 9a

• Enter the Medicare Supplement member’s policy and/or group number preceded by MEDIGAP, MG, or MGAP.

• Item 9d must be completed if you enter a policy and/or group number in 9a.


Item 9b

• Enter the birth date (MM/DD/YYYY) and gender of the member.

Item 9c

• Leave this field blank if the Blue Plan secondary payer’s name is entered in 9d.

• Enter the correct Blue Plan name as the secondary carrier in 9c. For example, if the member has a Medicare Supplement with Blue Cross and Blue Shield (BCBS) of Michigan, then BCBS of Michigan should be indicated as the secondary carrier, not Blue Cross and Blue Shield of Florida (BCBSF). Use an abbreviated street address, two letter postal code, and zip code copied from the member’s Medicare Supplement ID card. For example: 1234 Anywhere St, MD 12345.

Item 9d

• Enter the correct Blue Plan name as the secondary carrier.

Note: All information must be complete and accurate in items 9, 9a, 9b, 9c and 9d of the CMS-1500 form in order for the Medicare carrier to be able to forward claim information. If prior arrangements have been made with the private insurer, the carrier will forward the Medicare information electronically. Otherwise, the carrier will forward a hard copy of the claim to the private insurer.

Item 11d

• If you submit a claim with a Medicare Remittance Notice attached, always mark “YES” in 11d.

• If you mark “NO” in 11d, the claim will pass through the system but attachments will not be reviewed.

• If your billing system is hard-coded to mark “NO” automatically in 11d, please manually override your system to mark “YES” when submitting a claim with the Medicare Remittance Notice attached.


Item 13

• The signature in this item authorizes payment of mandated Medigap benefits to a participating physician or supplier if required Medicare Supplement information is included in items 9 through 9d.

• The member or member’s representative must sign this item or the signature must be on file as a separate Medigap authorization.

• The Medigap assignment on file in the participating physician or supplier’s office must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.

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