1. UB04 Medicaid Crossover Workshop
KyHealth Choices
UB04 Medicaid Crossover Workshop

2. Agenda Representative List Reference List 837 Requirements
Medicare EOB examples
Helpful Hints
How to Bill Medicare Primary Claims to KyHealth Choices
Evaluation

3. Representative List

4. Representative List

5. Reference List Helpful Phone Numbers Web Addresses EDS Website
EDI Helpdesk
Provider Billing Inquiry
Web Addresses
EDS Website
KyHealthnet
KyHealth Choices

6. Billing Crossovers to KyHealth Choices
Beginning September 29, 2008, KyHealth Choices will require their providers to prepare their own Medicare/Medicaid related claims.
If you bill these by paper, your claim form must include the Medicare information necessary for processing.
You will no longer send Medicare EOB’s with your claim unless Medicare denies the service.
You may bill Crossover claims by electronic means.

7. 837I Claims Submission
The 837I Companion Guide Version 3.0 will be available on the EDS website
Contact your Software Vendor to check the capability and readiness for these changes.

8. 837 Requirements
Loop 2320 CAS02 - Adjustment reason code '1' deductible or '2' Co-insurance
Loop 2320 AMT02 - Payor Paid Amount = Medicare paid amount
Loop 2320 AMT01 Amount Qualifier Code = 'B6' Payor Allowed amount
Loop 2320 AMT02 - Payor Paid Amount = Medicare Allowed amount
Loop 2330B DTP01 Date/Time Qualifier = '573' Medicare EOB pay date
For questions please contact EDI at

9. Required Information Medicare EOB Date Form Locator 37 (new change)
Medicare Paid Amount
Form Locator 54 (new change)
Medicare Allowed Amount
Form Locator 55 (new change)
Medicare Coinsurance Amount
Form Locator 39
Medicare Deductible Amount

10. Helpful Hints
A submission on paper or by electronic means must not be sent until you are sure the Medicare electronic Crossover was unsuccessful or denied by KyHealth Choices to avoid duplicate billing.
If Medicare denied your charges, the claim must still be submitted to KyHealth Choices by paper with the Medicare EOB attached.

11. UB 04 Top Half

12. UB 04 Bottom Half

13. Medicare EOB

14. UB04 Top Half (Blank)

15. UB04 Bottom Half (Blank)

16. Medicare EOB

17. UB04 Top Half (Blank)

18. UB04 Bottom Half (Blank)

19. Medicare EOB

20. UB04 Header with Medicare #1

21. UB04 Header with Medicare #2

22. UB04 Deductible for Medicare

23. Co-Insurance for Medicare

24. Summary with Medicare (Top)

25. Summary with Medicare (Bottom)