October 2009

UB-04 Medicare Crossover Claims

Presented by EDS Provider Relations

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Agenda

•Session Objectives•Crossover Claim – Defined•Automatic Crossover•Claim filing limit•Claims partially paid by Medicare•How To Bill A Crossover Claim•Helpful Tools

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Session Objectives

To have a general understanding of the following:

•Definition of a crossover claim

•Where to insert crossover information on the UB-04 claim form

•Where to input crossover information on Web interChange claims

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Crossover Claim - Defined

The term, “crossover claim” applies when a member has Medicare as the primary insurance, and:

•The Medicare coverage is from traditional Medicare, not one of the Medicare Replacement (or Medicare HMO) plans

•Medicare issued a payment of any amount, or the entire payment was applied to the deductible

A claim is not a crossover claim when:

•The member’s primary insurance is not traditional Medicare

•Medicare denied the entire claim

•Medicare benefit exhaust claim

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Automatic Crossover

Following are some of the reasons why claims fail to cross over from Medicare automatically

•The Medicare intermediary is not National Government Services (NGS) or is not an intermediary that has a partnership agreement with EDS

•Ambulatory surgical center (ASC) claims billed to Medicare on a CMS-1500 claim form with the SG modifier

•Data errors on the crossover file

– Examples include incorrect Social Security number

(SSN) or spelling of member name

Why Claims Do Not Cross Over Automatically

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Claim Filing Limit

•The standard filing limit for Medicaid claims is one year from the date of service

•Crossover claims are not subject to the one-year filing limit

– Crossover claims may be submitted and processed irrespective of the age of the claim

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Claims Partially Paid by Medicare

•When Medicare allows only some of the services on the claim:

– Only the Medicare-allowed services apply to crossover logic

• These services should be billed to Medicaid separately from the Medicare-denied services

• Providers should not send the Medicare Remittance Notice (MRN) to Medicaid when billing these services

– Only the Medicare-allowed services are exempt from the one-year filing limit

– Services denied by Medicare are subject to the one-year filing limit

• These services should be billed separately to Medicaid with a copy of the MRN

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How To Bill A Crossover Claim

• Identify Medicare Remittance Notice (MRN) information as follows:

– Value Code A1 – Medicare deductible amount

– Value Code A2 – Medicare co-insurance amount

– Value Code 06 – Medicare blood deductible amount

– Value Code 80 – IHCP covered days

Form Field 39

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How To Bill A Crossover Claim

•Field 50a - Enter the word “Medicare”

•Field 54a – Enter the amount paid by Medicare

Form Fields 50a through 54a

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How to Bill a Crossover on Web interChange

• From the Claim Submission Menu, select Institutional or Outpatient Crossover

• Complete the claim information• Select “Benefits Information” to enter the Coordination of

Benefits information• Complete the following fields:

– Payer ID (00130 for Part A; 00630 for Part B)– Payer Name– TPL/Medicare Paid Amount– First Name– Last Name– Primary ID– Relationship Code– Gender– Date of Birth– Claim Filing Code (MA for Part A; MB for Part B)

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•After entering the Coordination of Benefits information at the header level

– Click Save Benefits

– Click Save and Close

– Submit claim

• It is not necessary to enter coordination of benefits information at the detail level

How to Bill a Crossover on Web interChange

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Web interChange – Claims Processing Menu

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Institutional Claim

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Coordination of Benefits

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Coordination of Benefits

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Helpful Tools

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual, Chapter 8, Section 2 (Web, CD-ROM, or paper)

•Customer Assistance

– 1-800-577-1278, or

– (317) 655-3240 in the Indianapolis local area

•Written Correspondence

– P.O. Box 7263Indianapolis, IN 46207-7263

•Provider Relations field consultant

Avenues of Resolution

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Questions

October 2009

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