HIPAA: Crossovers
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What is a crossover claim?
A:
A claim for a beneficiary who is eligible for both Medicare and Medi-Cal where Medicare pays a portion of the claim and Medi-Cal is billed for the remaining deductible and/or coinsurance.
Q: What are the crossover system enhancements that implemented October 24, 2005?
A:
- Beginning October 24, 2005, crossover claims which do not automatically crossover from Medicare can be billed via CMC claim submission. Medi-Cal accepts crossover claims via CMC claim submission using the ASC X 12N 837 v.4010A1 for both Professional and Institutional claims, such as most inpatient, outpatient, skilled nursing facility, medical and vision claim types.
- Beginning October 24, 2005, Medi-Cal began accepting Medicare Part B pharmacy drug claims in the NCPDP 1.1 format. For claims that do not automatically crossover to Medi-Cal, it is necessary to bill these claims to Medi-Cal on pharmacy paper claim forms 30-1 or 30-4.
- Beginning October 24, 2005, Part B services billed to Part A intermediaries (Mutual of Omaha and UGS) will start to crossover automatically if the outpatient provider's Medicare number is included on their Medi-Cal Provider Master File.
- Beginning October 24, 2005, billing instructions for all providers submittting hardcopy outpatient crossover claims were changed to require a UB-92 Claim Form and the latest version of the PC Print single claim detail level Medicare National Standard Intermediary Remittance Advice.
Who are the Medicare Contractors?
A:
- Part A intermediaries: United Government Services (UGS) and Mutual of Omaha (MOH)
- Part B carriers: National Heritage Insurance Company (NHIC) North and South and CIGNA
- These are the only Medicare contractors that Medi-Cal receives electronic claims from, referred to as Tape-to-tape, Network Data Mover or automatic crossovers.
How can providers bill Medicare?
A:
Providers bill Medicare in one of the following ways:
Q: - Part A services billed to Part A intermediaries
- Part B services billed to Part A intermediaries
- Part B services billed to Part B carriers
When can we begin submitting crossover claims in CMC batches?
A:
Effective on October 24, 2005, Medi-Cal will accept crossover claims via CMC claim submission using the ASC X 12N 837 v.4010A1 for both Professional and Institutional claims. Submitters must test their crossover formats and be approved before their claims will be accepted into production. The Companion Guides have been updated to include the crossover modifications. CMC testing instructions can be found in the Testing and Activation Procedures section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual.
Q: Is this starting date based on Medicare claims paid on October 24, 2005? Or will this be for dates of services on or after October 24, 2005?
A:
For electronic claims, it is based on the files we receive from Mutual of Omaha and UGS for our cycle, effective 10/24/05. It is not based on Medicare claims paid 10/24/05 or date of service 10/24/05. For paper claims, it is based on claims received after 10/24/05.
Q: Are the hospitals automatically signed up for the outpatient Part B services billed to Part A intermediary (UGS) to crossover?
A:
Yes. The provider would need to have active provider numbers for both Medi-Cal and Medicare on file with
Medi-Cal. Once we have these numbers in the system, the system would be able to cross reference these numbers to verify provider eligibility.
Q: Does this require any special billing requirements to Medicare so that the claims crossover? For example, is there a field indicator on the 837 to Medicare to indicate the claim is a crossover?
A:
No. However, they should verify that Medi-Cal has the correct Health Insurance Card (HIC) number and Medicare provider number on file.
Q: Can I submit a crossover claim from County Health Systems (COHS)?
A:
Any NCPDP format retail pharmacy drug crossover claims submitted to Medi-Cal that should be directed to COHS will
be denied. These claims will not automatically be transferred to a COHS for payment like other Part B crossover claims are. Instead
providers must bill the COHS separately.
Q: What do providers have to do to make sure the claims are crossing over?
A:
Providers can check their Medicare remittance advice for code MA07.
Q: When the outpatient claims crossover will "No Pay" appear on the Medi-Cal RA?
A:
Yes. When an outpatient crossover claim pricing results in no payment by Medi-Cal RAD message 442 (Medicare payment meets or exceeds Medi-Cal maximum reimbursement), "No Pay" will appear on the Medi-Cal RA.
Q: If a hospital bills a claim to Medicare but does not indicate it is a crossover claim, will UGS be able to identify the crossover based on the Medicare patient ID number?
A:
Yes.
Q: If a claim does not automatically crossover and has to be hardcopy billed with an attachment or submitted electronically, how are the codes to be submitted?
A:
Providers should bill the claim with the same national codes that were submitted to Medicare.
Q: What are the crossover roll numbers?
A:
For Paper:
Q: - 08 Batches 90-96 Non-Compound Drug (claim form 30-1)
- 09 Batches 90-96 Compound Drug (claim form 30-4)
- 10-14 LTC
- 15-18 Inpatient
- 82 Outpatient
- 84 Medical
- 88 CIF
- 65 Batches 00-79 CMC
- 65 Batches 80-99 Drug
- 85, 86, 89 Medical
- 87 Outpatient
- 92 LTC/Inpatient
How do I get a Medicare National Standard Intermediary Remittance Advice to attach to my paper claim?
A:
The latest version of the free PC Print software from Medicare can be downloaded from the United Government Services Web site. Please note that providers who continue billing crossover claims on paper for Part B services billed to Part A intermediaries, the UB-92 Claim Form is required with the detail single claim version of the Medicare National Standard Intermediary Remittance Advice (RA). To avoid this paper billing requirement providers may bill electronically instead.
Q: How is the code conversion being handled?
A:
For HCPCS, they are processed using the national codes submitted to Medicare.
Q: Can an adjustment be a crossover?
A:
No. The provider has to file a paper claim for any adjustment.
Q: Are there types of claims or services that won’t automatically crossover?
A:
Yes. Claims for recipients with Other Health Coverage, share of cost or managed care, claims for Medicare contractors that we don’t have trading partner agreements with, unassigned claims, claims with an invalid Health Insurance Card number, and claims for providers that do not have a current Medicare provider number on their Medi-Cal Provider file.
Q: Will a provider be required to re-submit their claim by paper if it does not crossover automatically?
A:
No. Providers can send in an electronic claim with the proper Coordination of Benefit (COB) loops/segments.
Q: Can a provider bill an electronic crossover for pharmacy supplies?
A:
Yes, providers can bill through CIGNA, and if it does not crossover, they can either re-bill electronically through CMC with the 837 Professional form using the proper COB segments or paper bill using the CMS 1500 (HCFA 1500) form with the proper Medicare Remittance Notice.
Q: What is the process to get the Health Insurance Claims Number linked in the Medi-Cal eligibility file?
A:
For the recipient eligibility file, the patient would need to go to the Department of Social Services and notify their worker they wanted Medicare eligibility. EDS/DHS do not provide eligibility in this case.
For the provider eligibility file, the provider would need to have active provider numbers for both Medi-Cal and Medicare and submit their Medicare billing number to DHS Provider Enrollment Branch (PEB) on the DHS 6209, DHS 6207, and DHS 6208 applications. The processing time is around six months, so the provider would need to submit paper crossovers until their application is completed by PEB. Once we have these numbers in the system, the system would be able to cross reference these numbers to verify provider eligibility.
Q: For the provider eligibility file, the provider would need to have active provider numbers for both Medi-Cal and Medicare and submit their Medicare billing number to DHS Provider Enrollment Branch (PEB) on the DHS 6209, DHS 6207, and DHS 6208 applications. The processing time is around six months, so the provider would need to submit paper crossovers until their application is completed by PEB. Once we have these numbers in the system, the system would be able to cross reference these numbers to verify provider eligibility.
For new hardcopy billing requirements, the new instructions from EDS read that Box 56 on the
UB-92 Claim Form should contain the Medicare Intermediary number. On the example, it shows a five-character number; however, on the 835 that field contains a 10-character number.
A:
There is no reference to Box 56 on the 835. However, if the provider was referring to the 837 transaction, then Box 56 is the field that EDS will look for the five-digit Medicare Intermediary number (i.e., 00450).
Q: I’m a retail pharmacy provider, can I bill my crossover claims electronically via NCPDP?
A:
No. If your NCPDP claims do not crossover from CIGNA automatically you must bill retail pharmacy drug claims with NDC codes on the pharmacy paper claim forms 30-1 or 30-4.
Q: Why are my payments different now that my claims are crossing over to Medi-Cal automatically from Medicare?
A:
The Medi-Cal payment system was changed to correctly use comparative pricing and actual values rather than calculated service line details to determine the payment on your claim. This means that Medi-Cal will pay its rate for a service less the Medicare payment and beneficiary share of cost up to the coinsurance and deductible billed on the claim. Services that were denied or not covered by Medicare or were 100% paid by Medicare will not be paid when billed on a crossover claim.
Q: Why are my automatic Part B crossover claims for service code 92015 that used to pay $8.01 now being denied?
A:
Medi-Cal will now only pay for this service when billed on a regular Medi-Cal claim as a Medicare non-covered service.
Q: Why are my claims for psychotherapy services paying differently?
A:
The Medi-Cal payment system was updated to correctly calculate the payment for these claims.
Q: Why aren’t my NCPDP drug claims paying the full coinsurance and deductible any more?
A:
These claims are now subject to comparative pricing, meaning Medi-Cal will pay its rate for the drug based on the NDC code billed less the Medicare payment and beneficiary share of cost up to the coinsurance and deductible amount billed on the claim.
Q: Why are my outpatient claims paying under my Medi-Cal inpatient provider number?
A:
This is a system error that is in the process of being fixed. EDS will adjust these claims automatically in the future. Watch for updates on the Medi-Cal Web site.
Q: I am an FQHC provider with Medi-Cal but not Medicare. Why are my claims crossing over automatically and paying under my Medi-Cal outpatient provider number?
A:
If your Medicare provider number is attached to your Medi-Cal outpatient provider number your claims will cross over automatically. To avoid this you need to contact DHS provider enrollment to remove your Medicare number from your file. Any claims paid incorrectly will need to be adjusted.
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