Mastering Medicare Crossover Claims: How to File and Verify
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How to determine if the claim was crossed over from Medicare
If a claim is crossed over, you will receive a message beneath the patient’s claim information on the Payment Register/Remittance Advice that indicates the claim was forwarded to the carrier.
Example 1: “Claim information forwarded to: BCBS of Louisiana-Supplemental
Example 2: “Claim information forwarded to: BCBS of Alabama
When a Medicare claim has crossed over, providers are to wait 30 calendar days from the Medicare remittance date before submitting a claim to Blue Cross and Blue Shield of Louisiana. Claims you submit to the Medicare intermediary will be crossed over to Blue Cross only after they have been processed by Medicare. This process may take approximately 14 business days to occur. As a result, upon receipt of the remittance advice from Medicare, it may take up to 30 additional calendar days from the crossover for you to recieive payment or instructions from Blue Cross.
If the remittance does not contain a message similar to the above, the claim was not crossed over to the payer. This claim must be filed on paper to the Plan listed on the member’s ID card. The following claims are excluded from the crossover process for Blue Cross:
• Original Medicare claims paid at 100 percent
• 100 percent denied claims with no additional beneficiary liability
• Adjustment claims that are non-monetary/statistical
• Medicare Secondary Payer (MSP); claims for which other insurance exists for beneficiary
• National Council for Prescription Drug Programs (NCPDP) claims
What to do when the claim WAS NOT crossed over from Medicare For Louisiana claims that did not crossover automatically (except for Statutory Exclusions), the provider should wait 31 days from the date shown on the Medicare remittance to resubmit the claim. Claims submitted before 31 days will be rejected on the Blue Cross and Blue Shield of Louisiana Not Accepted Report.
After 31 days, the claim that did not crossover can be submitted electronically in the 837 format (if ending through a clearinghouse, verify your clearinghouse allows the electronic submission of these claims) or on a paper claim form (CMS-1500 or UB-04) along with a copy of the Medicare remittance advice.
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:
• 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.
• Enter the birth date (MM/DD/YYYY) and gender of the member.
• 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.
• 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.
• 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.
• 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. Follow-up on Crossover Claims Blue Cross Blue Shield of Louisiana:
• Wait 21 days before conducting follow-up on iLinkBLUE Blue Cross Blue Shield out-of-state plans:
• Wait 30 days before contacting the out-of-state plan Services Excluded or Not Covered by Medicare When a charge is considered excluded or not covered, providers are not required to wait the 31 days to file the claim. The claim should contain a GY modifier with the specific, appropriate, HCPCS code, if available. If there is not a specific HCPCS code, a “not otherwise classified code” (NOC) must be used with the GY modifier.
These claims can be filed electronically or on paper to Blue Cross and Blue Shield of Louisiana.
The crossover process allows providers to submit a single claim for individuals dually eligible for Medicare and Medicaid, or qualified Medicare beneficiaries eligible for Medicaid payment of coinsurance and deductible to a Medicare fiscal intermediary, and also have it processed for Medicaid reimbursement.
Refer to the specific claim type chapters within this manual for further billing instructions. Additional information about the crossover claim process is available on the MDHHS website. (Refer to the Directory Appendix for website information.)
ACCEPTABLE CROSSOVER CLAIMS
MDHHS accepts Medicare Part A institutional claims (inpatient and outpatient) and Medicare Part B professional claims processed through the CMS Coordinator of Benefits Contractor, Group Health, Inc.
(GHI). Claim adjudication will be based on the provider NPI number reported on the claim submitted to Medicare.
When a claim is crossed over to MDHHS, a remittance advice (RA) will be generated from the fiscal intermediary with the details of the Medicare payment and Remark Code MA07 (the claim information has also been forwarded to Medicaid for review). If this remark does not appear on the fiscal intermediary’s RA, a separate claim will have to be submitted to MDHHS.
CLAIMS EXCLUDED FROM CROSSOVER PROCESS
The following types of claims will be excluded from the crossover process between MDHHS and Medicare:
** Totally denied claims
** Claims denied as duplicates or missing information
** Replacement claims or void/cancel claims submitted to Medicare
** Claims reimbursed 100 percent by Medicare
** Claims for dates of service outside the beneficiary’s Medicaid eligibility begin and end dates Providers must resolve denied claims with the fiscal intermediary unless the service is an excluded benefit for Medicare, but covered by Medicaid (e.g., insertion of an IUD or hearing aid supply). In those cases, the excluded Medicare service can be billed directly to MDHHS.
Crossover Claim Follow-Up
Tracing Claims A Claims Inquiry Form (CIF) cannot be submitted to trace an automatic crossover claim.
However a CIF must be submitted to trace a direct billed crossover claim. Submit a crossover claim (CMS-1500/UB-04 with an MRN or Medicare RA) to trace an automatic crossover claim.
Claims Inquiry Form (CIF)
A CIF is used to initiate an adjustment or correction on a claim. The four ways to use a
CIF for a crossover claim are: • Reconsideration of a denied claim • Trace a claim (direct billed claims only) • Adjustment for an overpayment or underpayment • Adjustment related to a Medicare adjustment
Crossover CIF Billing Tips
Follow these billing tips to help prevent rejections, delays, mispayments and/or denials of crossover CIFs: • Submit only one crossover claim (that is, only one Claim Control Number [CCN]) for each CIF. • Enter the 13-digit CCN of the most recently denied crossover claim from the RAD in Box 9. • Mark Attachment field (Box 10) and include appropriate documentation that is clear, concise and complete. • Mark Underpayment field (Box 11) or Overpayment field (Box 12), if applicable. • If requesting an adjustment, use the approved CCN that is being requested for adjustment. • In the Remarks field (Box 80)/Additional Claim Information field (Box 19), indicate the reason for the adjustment or the denial, the type of action desired, and corrected information. • Failure to complete the Remarks field of the CIF may cause claim denial or delayed processing. • Make sure timeliness requirements are met.
It is acceptable to make corrections on the claim copy being submitted with the CIF if the Remarks field (Box 80)/Additional Claim Information field (Box 19) is completed.
Crossover Pricing Examples
This section has examples of Medicare/Medi-Cal claims for medical and outpatient services billed on the CMS-1500 and UB-04 claim forms as well as corresponding Remittance Advice Details (RAD) code examples.
Welfare and Institutions Code (W&I Code), Section 14109.5 limits Medi-Cal’s payment of the deductible and coinsurance to an amount that, when combined with the Medicare payment, should not exceed the amount paid by Medi-Cal for similar services. This limit is applied to the total sum of the claim. Therefore, the combined Medicare/Medi-Cal payment for all services of a claim may not exceed the amount allowed by Medi-Cal for all services of a claim.
NOTE Medicare deductible and coinsurance amounts that are hard copy billed are reimbursed as if they were automatically transferred from the Part B carrier.
Remittance Advice DetailsThe Medi-Cal RAD form shows each crossover service that was processed. For each procedure listed on the RAD form, the Medicare Allowed, Medi-Cal Allowed, Computed MCR AMT (Medicare payment) and Medi-Cal Paid amounts are shown. If Medi-Cal reduces or denies payment consideration for total claim services, the corresponding RAD code is included.