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									CMS-1500 – Medicare
Crossover Claim Billing


HP Provider Relations
October 2011
Agenda

– Session Objectives

– Crossover Claim – Defined

– Crossover Claims via Web
    interChange
– Crossover Claims via CMS-
    1500 Claim Form
– Reimbursement Methodology

– Automatic Crossover

– Common Denials

– Helpful Tools

– Questions

2   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Objectives

Following this session, providers will:
–   Know the definition of a crossover claim
–   Understand how to report crossover information on Web
    interChange
–   Understand how to report crossover information on the CMS-
    1500 claim form
–   Understand the difference between crossover and third-party
    liability (TPL) claims
–   Understand how crossover claims are reimbursed




3   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Define
  Crossover Claim
Crossover Claim – Defined

    The term “crossover claim” is
    defined as allowed line items billed
    to Traditional Medicare Part A
    and/or Part B and applies when a
    member has Medicare as the
    primary insurance:
    –    The Medicare coverage is not
         from one of the Medicare
         Replacement (or Medicare HMO)
         plans
    AND
    –    Medicare issued a payment of
         any amount, or the entire
         payment was applied to the
         deductible

5       CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover Claim – Defined

A claim is not a crossover claim
when:
–   The member’s primary insurance
    is not Traditional Medicare
–   Medicare denied the entire claim
    •   In this instance, the claim is a straight
        Medicaid claim and is subject to the one-
        year filing limit
    •   These claims are also subject to prior
        authorization requirements


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



6   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Learn
  Crossover Claims – Web interChange
Crossover Claims via Web interChange

–   Crossover information must be
    reported for both the header and
    detail levels
–   Header information is reported in
    the Benefit Information window
    • Header information pertains to the entire
      claim

–   Detailed information is reported in
    the Detail Benefits Info window
    • Detail information pertains to individual
      detail lines of the claim




8   CMS-1500 – Medicare Crossover Claim Billing   October 2011
9   CMS-1500 – Medicare Crossover Claim Billing   October 2011
10   CMS-1500 – Medicare Crossover Claim Billing   October 2011
11   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Coordination of Benefits
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     CMS-1500 – Medicare Crossover Claim Billing       October 2011
Coordination of Benefits




13   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Coordination of Benefits




14   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover Claims via Web interChange
Crossover header information

 – To report header information, perform the following:
      • Click Benefit Information on the Claim Submission screen
      • Payer ID = 00630
      • Payer Name = Medicare Part B
      • TPL/Medicare Paid Amount = The total amount paid by Medicare for the claim
      • Subscriber Name
      • Primary ID = Medicare number w/ alpha
      • Relationship Code = 18 (self)
      • Gender
      • Date of birth
      • Claim Filing Code = MB



15   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover Claims via Web interChange
Crossover header information

 – To report header information, perform the following:
      • Click Save Benefits at the bottom of the screen

      • Scroll to the top of the screen and Click Save and Close




16   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Learn
 Crossover Claims Detail Information –
 Web interChange
Crossover – Detail Screen




18   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover – Detail Screen                          Detail line paid amount



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19   CMS-1500 – Medicare Crossover Claim Billing              October 2011
Crossover – Detail Screen




20   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover – Detail Screen




21   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover Claims via Web interChange
Crossover detail information

 – To report detail information, perform the following:
      • Click Detail Benefits Info

      • Payer ID = 00630

      • TPL/Medicare Paid Amount = Enter the amount paid by Medicare for the
         highlighted detail line only

      • Click Save Payer

      • Group Code = Enter CO

      • Reason Code = Enter 1 for deductible, 2 for coinsurance, and 122 for
         psychiatric reduction

           – Do      not report write-off or contractual adjustment/discount amounts

      • Amount = Enter the amount of the deductible and/or coinsurance

22   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Crossover Claims via Web interChange
Crossover detail information

 – To report detail information, perform the following:
      • Click Save Group Code

      • Scroll to the top of the screen and Click Save and Close

 – At the bottom of the Claim Submission screen, click on the next
   detail line, be sure it is highlighted in blue and repeat the steps
   to complete the Detail Benefits Info screen
      •   Complete this screen for each line of detail on the claim

      Note: Claims for rural health clinics (RHCs) and Federally
            Qualified Health Centers (FQHCs) that did not cross over
            electronically should be rebilled with code T1015 added to
            the claim


23   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Detail
  Crossovers – CMS-1500 Claim Form
Crossovers
CMS-1500 claim form

 – Field Locator 22 is used to report crossover information
 – Left side – Medicaid Resubmission Code = sum of the Medicare
   coinsurance, deductible, and psychiatric reduction
 – Right side – Original Ref. No. = Actual amount paid by Medicare
 – Do not report crossover information in field locator 29
 – Crossover claims are mailed to:
      •   HP Medical Crossover Claims
          P O Box 7267
          Indianapolis, IN 46207-7267




25   CMS-1500 – Medicare Crossover Claim Billing   October 2011
CMS-1500 Claim Form




26   CMS-1500 – Medicare Crossover Claim Billing   October 2011
CMS-1500 Claim Form – Fields 22 and 29
                                    Sum of
                                 Coinsurance,                         Payment
                                 Deductable,                        received from
                                  and Psych                           Medicare
                                  Reduction

     22. MEDICAID RESUBMISSION
         CODE                                                          ORIGINAL REF. NO.



                                            Do not enter
                                             Medicare
                                            payment in
                                              field 29

                               29. AMOUNT PAID
                                  $

27   CMS-1500 – Medicare Crossover Claim Billing     October 2011
Explain
  Reimbursement Methodology
Reimbursement Methodology

–    IHCP makes payment on
     crossover claims only when the
     total Medicaid rate for the entire
     claim exceeds the amount paid by
     Medicare for the entire claim
–    IHCP reimbursement includes the
     lesser of the:
     • Medicare coinsurance and deductible
              OR

     • Difference between the IHCP rate and the
       Medicare paid amount for the entire claim




29   CMS-1500 – Medicare Crossover Claim Billing   October 2011
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
     •   Allowed 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 allowed 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
     •   These services are also subject to all PA requirements




30   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Describe
  Automatic Crossover
Automatic Crossover
Why claims do not cross over automatically

 – Following are some of the reasons why claims fail to cross over
   from Medicare automatically
      • Failure to establish a one-to-one match of the National Provider Identifier (NPI)
         and the Legacy Provider Identifier (LPI)

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

      • Member has a secondary insurer other than Medicaid

      • 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


32   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Deny
 Common Denials
Edit 2502

 Recipient covered by Medicare Part B
 –   Cause
     • Medical claims for Medicare Part B coverage for a member have Part B on the
       eligibility screen but there is no Medicare MRN with the claim showing Medicare denial

 –   Resolution
     • Submit the Medicare payment on the right side of field 22 and sum of the
       coinsurance, deductible, or blood deductible on the left side

 – Resolution
 • Submit the coordination of benefits information




34   CMS-1500 – Medicare Crossover Claim Billing   October 2011
Edit 558
Coinsurance and deductible amount missing
–    Cause
     • Coinsurance and deductible amount is missing indicating this is not a crossover claim

–    Resolution
     • Add coinsurance and/or deductible amount and/or Medicare paid amount to the CMS-
       1500
     • CMS-1500
           Add         coinsurance and/or deductible amount on the left side of field 22
           Add         the Medicare Payment amount on the right side in field 22




35   Enroll Providers: An Overview of Provider Enrollment   August 2010
Edit 2505
Recipient covered by private insurance
–    Cause
     • This member has private insurance, which must be billed prior to Medicaid

–    Resolution
     • Add the other insurance payment to the claim
     • CMS-1500
           Add         other insurance excluding Medicare payments to field 29
     • If the primary insurance denies, the explanation of benefits (EOB) must be sent with
       the claim, either on paper with a paper claim, or as an attachment if claim is sent on
       Web interChange




36   Enroll Providers: An Overview of Provider Enrollment   August 2010
Find Help
  Resources Available
Helpful Tools
Avenues of resolution


– IHCP website at
  indianamedicaid.com
– IHCP Provider Manual (Web, CD, or
  paper)
– Customer Assistance
      •   1-800-577-1278, or

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

– Written Correspondence
      •   P.O. Box 7263
          Indianapolis, IN 46207-7263

– Provider field consultant

 38       CMS-1500 – Medicare Crossover Claim Billing   October 2011
Q&A

								
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