Filing for UB-04 - Medicare Crossover Claims

When to File Crossover Claims

The provider may submit a crossover claim to Medicaid by paper claim or electronically when:
• Medicaid is still liable for a portion of the claim;
• There is no automated crossover arrangement with the intermediary;
• The intermediary did not forward the claim to Medicaid;
• It has been over 45 days from Medicare’s payment and no remittance has been received from Medicaid;
• Medicare denied the claim;
• Medicare adjusted or voided the claim; or
• The recipient has an additional third party payer.

How to File Paper Crossover Claims on the UB-92

The following are step-by-step instructions for filing a paper crossover claim:
• Submit a legible photocopy of the UB-04 claim form that was submitted to Medicare. If there is no copy of the Medicare claim or Medicare is billed electronically, prepare a UB-92 claim form according to Medicare

• Enter the word “CROSSOVER” in form locator 2.
• Enter the nine-digit Medicaid provider number in form locator 51B.
• Ensure that the recipient’s ten-digit Medicaid number is in form locator 60B; form locator 60A must contain the recipient’s Medicare number.
• Circle the corresponding claim information on the Medicare Remittance Advice (RA). Do not highlight or use liquid correction fluid. Paper clip the RA to the back of the UB-92 claim.

Where to Submit the UB-92 Crossover Claim

Submit the claim and the attached Medicare RA to:

UB-92 Crossover Claims
P.O. Box 7064
Tallahassee, Florida 32314-7064

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