Avoiding Medicare/Medicaid Crossover Claims Rejections

If your Medicaid crossover claims are rejecting it may be due to the address you have on file with Medicare and Medicaid. When Medicare crosses over your claim to Medicaid, address fields like Master address and Pay-to (or remit address) are submitted. If Medicaid does not have the same addresses in their file, Medicaid will reject the claim.

Medicaid validates the crossover claims as follows:

  • National provider identifier (NPI)
  • NPI to taxonomy code (if applicable)
  • NPI to ZIP code

Avoiding Medicare/Medicaid Crossover Claims Rejections

You can avoid such rejections by:

  • Verifying that you have the exact same addresses on file with both Medicare and Medicaid
  • Making sure your addresses are current and, in the ZIP+4 (i.e., nine-digit ZIP code) format

Updating your Medicare Enrollment Record

If you do not have the correct addresses on file with Medicare, please update your enrollment file by completing the appropriate CMS-855 form. To expedite the processing of your application, please use the internet-based Provider Enrollment, Chain, and Ownership System (PECOS).

Updating your Medicaid Enrollment Record

You can update your addresses with Medicaid with two options:

  • Access Medicaid’s secure web portal, click on “Demographics” and then “Address,” to update the address.
  • Contact Medicaid’s provider enrollment customer service lines and they will fax the appropriate paperwork to you.

Medicaid also requires a notarized copy of your W9 – showing your new address, which may be submitted via fax. You may use Medicaid’s web portal to create a fax cover sheet, which should include: Attention: Provider Enrollment. Medicaid also recommends that you add your provider ID number to all pages within your document (including the fax cover sheet).

Few Things to Remember

  • Providers are responsible for establishing internal billing procedures to ensure that Medicaid recipients are not being inappropriately billed for Medicare/Medicaid Services.
  • If a recipient has both Medicare and Medicaid coverage, providers should file claims in the appropriate manner with the regional Medicare intermediary/carrier, making sure the recipient’s Medicaid number is included on the Medicare claim form.
  • Once the Medicare intermediary/carrier has processed/paid their percentage of the approved charges, Medicare will electronically submit a “crossover” claim to the Medicaid FI that includes the co-insurance and/or deductible.
  • If the “crossover” claim is denied by Medicare, the provider must submit a corrected claim to Medicare, if applicable.
  • If the “crossover” claim is not automatically crossed from Medicare and received by Medicaid, then the provider must submit a hard copy claim for payment of Medicaid’s responsibility as appropriate.
  • Please note that Medicaid does not necessarily pay the full Medicare deductible and co-insurance on a claim. A cost-comparison methodology has been used in the payment of Crossover claims for many years. Providers may not balance-bill recipients in these instances.
  • Dual eligible is recipients who have Medicare and Medicaid coverage. Medicaid will reimburse the provider an amount up to the full amount of Medicare’s statement of liability for co-insurance and deductible for Qualified Medicare Beneficiaries (QMB).
  • For claims in which Medicare’s reimbursement exceeds the maximum allowable by Medicaid, Medicaid will “zero” pay the claim. Such claim is considered “paid in full” and the provider may not seek additional remuneration from the recipient.
  • Medicaid will pay up to the Medicare deductible and coinsurance on Medicare-approved claims for non-Qualified Medicare Beneficiaries (non-QMB) receiving both Medicare and Medicaid, provided the procedure is covered by Medicaid.
  • Medicaid will reimburse the provider an amount up to the full amount of Medicare’s statement of liability for co-insurance and deductible as long as it does not exceed Medicaid’s allowable reimbursement for the service. Medicaid will “zero’ pay the claim when Medicare’s reimbursement exceeds the maximum allowable by Medicaid.

Medical Billing for Medicare or Medicaid requires great expertise in medical billing and coding for a given specialty. Providers dedicating a major portion of their time on patient management find it difficult to stay on top of Medicare/Medicaid billing updates.

In such a case, you can always take assistance from an expert medical billing company like Medical Billers and Coders (MBC). For any assistance in Medicare/Medicaid billing and coding, contact us at 888-357-3226/ info@medicalbillersandcoders.com.