1. UB-04 Medicare Crossover Claims
HP Provider Relations
October 2011

2. Agenda Objectives What is a Medicare Crossover Claim
Billing Electronically
Billing Paper Claims
Supporting Documentation
ANSI version 5010
Helpful Tools
Questions

3. Session Objectives
At the end of this session, providers will understand:
What constitutes a Medicare crossover claim
What supporting documentation is required
How to identify and notate the supporting documentation
What actions to take in preparation of ANSI version 5010

4. Learn
Medicare Crossover Claims

5. Medicare 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
It is a Medicare benefit exhaust claim

6. Why Claims Do Not Automatically Cross Over
Following are some of the reasons why claims fail to cross over from Medicare automatically:
NPI one-to-one match cannot be accomplished
The Medicare intermediary is not National Government Services (NGS) or is not an intermediary that has a partnership agreement with HP
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

7. 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

8. Claims Partially Paid by Medicare
When Medicare allows only some of the services on a nonsurgical outpatient 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 for services Medicare has paid
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

9. Bill
Electronic Crossover Claims

10. Web interChange – Claims Processing Menu

11. Institutional Claim

12. Coordination of Benefits

13. Coordination of Benefits

14. Where Do I Find Documented Claim Filing Instructions?

15. Bill
Paper Crossover Claims

16. How to Bill a Crossover Claim
Identify Medicare Remittance Notice (MRN) information in field 39 as follows:
Value Code A1 – Medicare deductible amount
Value Code A2 – Medicare coinsurance amount
Value Code 06 – Medicare blood deductible amount
Value Code 80 – IHCP covered days

17. Crossover Claim

18. Where Do I Find Documented Claim Filing Instructions for Paper Claims?
Refer to Chapter 8 Section 2

19. Prepare
ANSI version 5010

20. HIPAA 5010
The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012
If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment
HP has been accepting test files from approved Trading Partners during 2011

21. HIPAA 5010 Transactions affected by this upgrade:
Institutional claims (837I)
Dental claims (837D)
Medical claims (837P)
Pharmacy claims (NCPDP)
Eligibility verifications (270/271)
Claim status inquiry (276/277)
Electronic remittance advices (835)
Prior authorizations (278)
Managed Care enrollment (834)
Capitation payments (820)

22. What You Need To Do If you bill IHCP directly
Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
If you are using a billing service or clearinghouse
Monitor their progress in preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0
Questions should be directed to OR
Call the EDI Solutions Service Desk
or (317)

23. Deny
Common Denials

24. Common Denials
0558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim
Cause
No coinsurance or deductible information is present on the claim
Resolution
Electronic – Complete the Benefit Information window on the Web interChange
Paper – Add A1 or A2 and amount in Field Locator 39

25. Common Denials
2501 – This recipient is covered by Medicare Part A; therefore, you must first file claims with Medicare
Cause
Claim has not been submitted indicating the coinsurance and deductible amount in Field 39, no attachment
Resolution
Electronic – Complete the Benefit Information window on the Web interChange
Paper – Add A1 or A2 and amount in Field Locator 39

26. Common Denials
2007 – Qualified Medicare Beneficiary (QMB) recipient – Please bill Medicare first
Cause
Member is a QMB and no Medicare payment is indicated on the claim
Resolution
Electronic – Complete the Benefit Information window on the Web interChange
Paper – Add A1 or A2 and amount in Field Locator 39

27. Find Help
Resources Available

28. Helpful Tools Avenues of resolution
IHCP website at indianamedicaid.com
Provider Enrollment
Customer Assistance
, or
(317) in the Indianapolis local area
Written Correspondence
P.O. Box Indianapolis, IN
Provider Relations field consultant

29. Q&A