HP Provider Relations
October 2011

– Objectives
– What is a Medicare Crossover Claim
– Billing Electronically
– Billing Paper Claims
– Supporting Documentation
– ANSI version 5010
– Helpful Tools
– Questions
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At the end of this session, providers will understand:
– What constitutes a Medicare crossover claim
– What supporting documentation is required
– How to identify and notate the supporting documentation
– What actions to take in preparation of ANSI version 5010
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Medicare Crossover Claims

– The term, “crossover claim” applies when a member has
Medicare as the primary insurance, and:
• The Medicare coverage is from traditional Medicare, not one of the
Medicare Replacement (or Medicare HMO) plans
• Medicare issued a payment of any amount, or the entire payment was applied to the deductible
– A claim is not a crossover claim when:
• The member’s primary insurance is not traditional Medicare
• Medicare denied the entire claim
• It is a Medicare benefit exhaust claim
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Following are some of the reasons why claims fail to cross over from Medicare automatically:
– NPI one-to-one match cannot be accomplished
– The Medicare intermediary is not National Government Services
(NGS) or is not an intermediary that has a partnership agreement with HP
– 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
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– The standard filing limit for
Medicaid claims is one year from the date of service
– Crossover claims are not subject to the one-year filing limit
• Crossover claims may be submitted and processed irrespective of the age of the claim
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When Medicare allows only some of the services on a nonsurgical outpatient claim:
– Only the Medicare-allowed services apply to crossover logic
• These services should be billed to Medicaid separately from the Medicaredenied services
• Providers should not send the Medicare Remittance Notice (MRN) to Medicaid when billing for services Medicare has paid
– Only the Medicare-allowed services are exempt from the oneyear 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
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Electronic Crossover Claims

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Paper Crossover Claims

– Identify Medicare Remittance Notice (MRN) information in field
39 as follows:
• Value Code A1
– Medicare deductible amount
• Value Code A2 – Medicare coinsurance amount
• Value Code 06
– Medicare blood deductible amount
• Value Code 80
– IHCP covered days
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– Refer to Chapter 8 Section 2
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ANSI version 5010

HIPAA 5010
– The mandatory compliance date for ANSI version 5010 and the
National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012
– If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment
– HP has been accepting test files from approved Trading Partners during 2011
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HIPAA 5010
– Transactions affected by this upgrade:
•Institutional claims (837I)
•Dental claims (837D)
•Medical claims (837P)
•Pharmacy claims (NCPDP)
•Eligibility verifications (270/271)
•Claim status inquiry (276/277)
•Electronic remittance advices (835)
•Prior authorizations (278)
•Managed Care enrollment (834)
•Capitation payments (820)
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– If you bill IHCP directly
• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
– If you are using a billing service or clearinghouse
• Monitor their progress in preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0
– Questions should be directed to INXIXTradingPartner@hp.com
OR
– Call the EDI Solutions Service Desk
• 1-877-877-5182 or (317) 488-5160
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Common Denials

0558 – Coinsurance and deductible amount is missing indicating that this is not a crossover claim
– Cause
• No coinsurance or deductible information is present on the claim
– Resolution
• Electronic – Complete the Benefit Information window on the Web interChange
• Paper – Add A1 or A2 and amount in Field Locator 39
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2501 – This recipient is covered by Medicare Part A; therefore, you must first file claims with Medicare
– Cause
• Claim has not been submitted indicating the coinsurance and deductible amount in
Field 39, no attachment
– Resolution
• Electronic – Complete the Benefit Information window on the Web interChange
• Paper – Add A1 or A2 and amount in Field Locator 39
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2007 – Qualified Medicare Beneficiary (QMB) recipient –
Please bill Medicare first
– Cause
• Member is a QMB and no Medicare payment is indicated on the claim
– Resolution
• Electronic – Complete the Benefit Information window on the Web interChange
• Paper – Add A1 or A2 and amount in Field Locator 39
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Resources Available

Avenues of resolution
– IHCP website at indianamedicaid.com
– Provider Enrollment
• 1-877-707-5750
– 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 Relations field consultant
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Q&A