HIPAA: Crossover Claims

  1. What is a crossover claim?

    A crossover claim is a claim for a recipient who is eligible for both Medicare and Medi-Cal, where Medicare pays a portion of the claim and Medi-Cal is billed for any remaining deductible and/or coinsurance.

  2. How do Medicare claims cross over to Medi-Cal?

    Medicare uses a Coordination of Benefits Contractor (COBC) to electronically, automatically cross over claims billed to the Medicare Part A, Part B and Durable Medical Equipment (DME) contractors for Medicare/Medi-Cal eligible recipients.

  3. Where can providers find paper billing instructions for crossover claims?

    Providers may refer to the Medi-Cal provider manual, which is available on the Medi-Cal website. Information regarding paper billing instructions for Medicare/Medi-Cal Crossover claims can be found in the Medicare/Medi-Cal Crossover Claim sections of the provider manual.

  4. Who are the Medicare contractors?

    • California's Part A & B Medicare Administrative Contractor (MAC) is Noridian Administrative Services
    • California’s DME Medicare Administrative Contractor (DME MAC) is
      Noridian Administrative Services
    • Medicare COBC: Group Health Incorporated (GHI)
  5. How can providers bill Medicare for crossover claims?

    Information in regard to Medicare’s Electronic Data Interchange (EDI) helpline numbers by jurisdiction can be found on the Overview page of the Centers for Medicare and Medicaid (CMS) website.

    Medicare providers bill Medicare in one of the following ways:
    • Part A services billed to Part A contractors
    • Part B services billed to Part A contractors
    • Part B services billed to Part B contractors
  6. How can providers verify their claims are crossing over?

    Providers can check their Medicare Remittance Advice (RA) for code MA07.

  7. What should providers do if a crossover claim does not automatically cross over electronically?

    If a crossover claim does not automatically cross over electronically providers can directly bill Medi-Cal electronically using the 5010A1 format or on paper.

  8. Why is the Patient Control Number (PCN)/Patient Account Number (PAN) returned on the Medi-Cal 835 RA shorter than what I sent to Medicare?

  9. The PCN/PAN on claims submitted to Medicare may be truncated below the required 20 bytes on some automatic crossover claims; therefore, providers may not receive the same PCN/PAN that was originally submitted to Medicare. All PCNs/PANs will be returned on the Medi-Cal 835 RA in the same format that Medi-Cal received them from Medicare.

Pharmacy Supplies and Claims in the NCPDP Format

  1. Can a provider bill an electronic crossover for pharmacy supplies?

    Yes. Providers can bill through the Medicare Administrative Contractor and if the claim does not cross over, providers can either re-bill electronically through Computer Media Claims (CMC) with the 837 Professional transactions using the proper COB segments, or paper bill using the CMS 1500 claim form with the proper Medicare Remittance Notice.

  2. Can a retail pharmacy provider bill crossover claims electronically via NCPDP?

    No. If a provider’s NCPDP claim does not cross over automatically, providers must bill retail pharmacy drug claims with the National Drug Codes (NDC) on the Medi-Cal pharmacy paper claim form 30-1 or 30-4.

  3. Can providers submit a crossover claim in the National Council for Prescription Drug Programs (NCPDP) format for a County Organized Health Systems (COHS) covered recipient?

    NCPDP retail pharmacy drug claims for dual eligible recipients should be submitted directly to the COHS. Medi-Cal will deny any NCPDP claim for a dual eligible recipient that should be directed to a COHS. These claims are not automatically transferred from Medicare through Medi-Cal to a COHS for payment, like other Part B crossover claims. Medi-Cal will accept NCPDP claims for products excluded from COHS coverage.