What is the Medicare Crossover Claim?

A crossover claim is a claim for a recipient who is eligible for both Medicare and Medicaid, where Medicare pays a portion of the claim, and Medicaid is billed for any remaining deductible and/or coinsurance. A Coordination of Benefits Contractor (COBC) is used to electronically, automatically cross over claims billed to Medicaid for eligible recipients.

Your Medicare remittance will have an indicator that will show the claim was an automatic cross over to Medicaid. When the indicator appears on the Medicare remittance you will not bill Medicaid for those clients. Providers can check their Medicare Remittance Advice/ Remittance Remark Code that will verify their claims are crossing over.

Medicaid Billing for Crossover Claims

  • You won’t have to submit claims directly to Medicaid for those Medicaid patients who have both Medicare (Parts A &/or B) and Medicaid. In most instances, there are no changes to how you bill Medicare however Institutional providers who submit with rate codes are encouraged to include the Medicaid rate code on their claim to Medicare.
  • The amount paid by Medicaid will be the deductible/coinsurance or co-pay amounts as indicated on the crossover claim from Medicare.
  • If a provider bills multiple lines to Medicare and Medicare pays one or more lines but denies the others, the paid line(s) (as long as there are PRs) will be crossed over to Medicaid and the provider must resubmit the crossover payment as an adjustment to Medicaid to add the additional lines. When Medicare claim payment is zero, that claim will still be crossed over and the deductible will be paid by Medicaid.
  • The NPI that is used on your Medicare claim must be enrolled with Medicaid. Your crossover claims will not be processed if the NPI on your Medicare claim is not enrolled with Medicaid. In this case, Medicaid will reject the crossover claim back to Medicare and Medicare will send a notification letter of the rejection to the provider.

What if I submit a claim directly to Medicaid for a patient who also has Medicare?

If the crossover claim from Medicare is processed first, the provider submitted claim will be denied as a duplicate claim. If the provider submitted claim is processed prior to the Medicare crossover claim, the provider submitted claim will be paid as it is today if the zero-fill indicator is included on the claim. When the crossover claim is received it will also be paid.

Avoiding Crossover Claim Rejections

If your Medicaid crossover claims are getting rejected, it may be due to the address you have on file with Medicare and Medicaid. When Medicare crosses over your claim to Medicaid these address fields are submitted: Master address, and Pay-to (or remit address) (if they are different on Medicare’s system). You can verify that you have the exact same addresses on file with both Medicare and Medicaid. If Medicaid does not have the same addresses in their file, Medicaid will reject the claim.

Updating Medicare/Medicaid Enrollment Record

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

Medicaid: Updating address with Medicaid can be done in two ways:

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

Note that Medicaid 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).

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