Medicare Crossover Reimbursement for CMS-1500 Billers

This section applies to the following Medicaid providers who bill Medicare on
the CMS-1500 claim form:

• Audiologists
• Chiropractors
• Community Mental Health Providers
• County Health Departments (see additional information below)
• Dentists
• Emergency Transportation (see additional information below)
• Home Health Agencies (Durable Medical Equipment services)
• Independent Laboratories
• Licensed Midwives
• Nurse Practitioners
• Optometrists
• Pharmacies (see additional information below)
• Physician Assistants
• Physicians (M.D., D.O.)
• Podiatrists
• Portable X-ray Companies


Medicaid Program Limits


Medicaid will not pay a CMS-1500 crossover claim if:
• The service provided is not covered by Medicaid;
• Medicare has already paid the claim in an amount that equals or exceeds Medicaid’s rate, or fee, for the
service;
• The Medicaid program limits for the service already have been met; or
• The combined amounts received from Medicare and any other third party
exceed the Medicaid fee for the service.

How to Determine Medicaid’s Fee

Subtract Medicare’s payment from the Medicaid fee. If the remainder is negative, Medicaid will not pay the crossover claim. If the remainder is positive, Medicaid can pay the deductible and coinsurance up to Medicaid’s maximum fee, per the fee schedule, minus the Medicaid copayment.


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 carrier;
• The carrier 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 adjusted or voided the claim; or
• The recipient has an additional third party payer.


How to File Part B Crossover Claims on the CMS-1500


The following are step-by-step instructions for filing a paper crossover claim:
• Submit a legible photocopy of the CMS-1500 claim form that was submitted to Medicare. If there is no copy of the Medicare claim or Medicare is billed electronically, prepare a CMS-1500 claim form according to Medicare guidelines.
• In field 1, enter Xs in the boxes labeled “Medicare” and “Medicaid.”
• Ensure that the recipient’s ten-digit Medicaid number is in field 10d; field 1a must contain the recipient’s Medicare number.
• If the recipient is enrolled in MediPass, the authorization number must be entered in field 17a.
• Enter the nine-digit Medicaid provider number in field 33. If field 33 contains a group provider number, enter the nine-digit Medicaid treating provider number in field 24K.
• Circle the corresponding claim information on the EOMB. Do not highlight. Paper clip the EOMB to the back of the claim.
• Sign and date the CMS-1500 claim form.

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