Medicare Crossover Claims. Conduent MS Medicaid Project Government Healthcare Solutions

Transcription

1 Medicare Crossover Claims Conduent MS Medicaid Project Government Healthcare Solutions

2 Crossover Claim Form Types CMS-1500 Part B (Traditional Medicare) UB-04 Part A (Traditional Medicare) Medicare Part C (Advantage/HMO) State Mandated Form Part B State Mandated Form Part A 2

3 Crossover Claim Part C (Advantage Plans) Professional Claims These claims should be filed on the MS Crossover State Mandated Claim form. This form must be used when billing for Medicare Part C Advantage Plans. An additional requirement is that a copy of the Medicare EOMB for the billed services must be attached for all paper crossovers. There must be an EOMB for each claim form. (Ex: If there are 9 lines, there should be two claim forms. An EOMB should be with each claim form.) 3

4 Crossover Claim Part C (Advantage Plans) Professional Claims 4

5 Crossover Claim Part C (Advantage Plans) Institutional These claims should be filed on the MS Crossover State Mandated Claim form. This form must be used when billing for Medicare Part C Advantage Plans. An additional requirement is that a copy of the Medicare EOMB for the billed services must be attached for all paper crossovers. Only one EOMB is required even in the event that there are multiple claim forms (same recipient). Header information must match the EOMB. 5

6 Crossover Claim Part C (Advantage Plans) Institutional 6

7 CMS 1500 Part B Traditional Medicare What information should be included on the CMS 1500 claim form? Be sure to include any/all information on the claim as it was submitted to Medicare. Enter X in the boxes labeled Medicare and Medicaid Important fact to remember when submitting the claim form. Do not enter the Medicare Payment amount in field 29. 7

8 UB04 Part A Traditional Medicare What information should be included on the UB04 claim form? Be sure to include any/all information on the claim as it was submitted to Medicare. Enter the word CROSSOVER in field 2. The only TPL payments that should be reported in field 54 of the UB04 are those other than Medicare and Medicaid. 8

9 Medicare EOMB Tips EOMB data should be legible The Medicare Header Information should be included Patient data should be in reference to the beneficiary billed on the claim (A line should be drawn through any other beneficiaries listed) Claim Line Details-Draw a line through line items that have already been paid by Medicaid 9

10 Top Denials Denial Code Description Resolution 0104 Exact Duplicate Claim Paid claim already on file. If applicable, the claim will need to be voided and resubmitted This HCPC code must be billed with an NDC Check the drug code billed and ensure that there is a rebatable NDC entered on the claim EOMB requires review or is missing or invalid The EOMB should be attached with the claim and have all claim data Exact Duplicate Claim Electronic Crossover vs. Electronic Crossover TPL Beneficiary has primary insurance coverage Resubmit with TPL EOMB Paid claim already on file. If applicable, the claim will need to be voided and resubmitted. Verify Primary Insurance coverage. Resubmit with primary EOMB Exceeds Timely Filing Claims must be submitted within 180 days from the Medicare paid date. 10

11 Tertiary Claims Tertiary Claims should be sent to: Conduent State Healthcare, LLC Attn: Rochelle McKinney P.O. Box Jackson, MS Include the claim and both EOMBs from the primary payers. 11

12 Helpful Hints What do I do if my crossover claim does not crossover from Medicare? The charges should be submitted to Medicaid via hardcopy claim or through the Web Portal along with a copy of the Medicare EOMB. Can I correct a crossover claim online? No. The claim should be voided and a new claim along with the Medicare EOMB should be submitted to Medicaid for consideration. 12

13 Helpful Hints If Medicare does not pay the claim but it should have, can I send it to Medicaid to pay? If Medicare does not pay for a service and they should have, the claim cannot be submitted to Medicaid without the Medicare EOMB. Who is considered a dual eligible beneficiary and what part of those claims can I bill to the patient? Dually eligible beneficiaries are those eligible for both Medicare and Medicaid. Dual eligible beneficiaries cannot be billed the difference between what the provider charges and the sum of the Medicare and Medicaid payment. 13

14 Helpful Hints Is it a regular Medicaid claim if the service is not covered by Medicare but is covered by Medicaid? Yes, if Medicare denies a claim and the procedure code is covered by MS Medicaid, a Medicare denial is considered to be a Medicaid primary claim. Is (non-emergency) transportation available for dual eligible beneficiaries? Claims may be filed for non-emergency transportation for dual eligible beneficiaries for services not covered by Medicare if the reason for the Medicare denial is other than medical necessity. What are the timely filing guidelines for crossover claims? 180 days from the Medicare paid date is the timely filing limitation for crossover claims. 14

15 Helpful Hints Are Part C claims crossed over from Medicare? Part C (Medicare Advantage) claims can only be submitted via paper on the appropriate claim form along with the Medicare Advantage EOMB. 15

16 Dos and Don ts 1. Do not staple your claims together. Providers can simply place their attachments behind the associated claims and place them in an envelope. 2. Sign the claim in ink. The vast majority of the claims are Returned to the Provider (RTP) because they are not properly signed. 3. Submit requests for Medicaid payment on Crossover form. Providers should send claims with Medicare Explanation of Benefits (EOB) showing that payment has been received from Medicare. 5. Do not send a stack of claims and one copy of the attachment that goes with each claim. If there is an attachment that is critical to the processing of the claim, copy the attachment for each claim and place it with the associated claim before submitting those claims for processing. 6. Submit standard 8 x 11 attachments. Strips, cutouts and the like are not acceptable. 7. Put the bill date on each claim. 4. List the Third Party Liability (TPL) payment in the appropriate field. For all claims submitted with TPL payments, the payment must be shown in the prior payments (UB-04) field and the amount paid in the (CMS-1500) field on the claim. 8. Place bill types on UB-04s and Crossover Part A forms. 9. Mail or electronically submit your claims. WE DO NOT ACCEPT FAXED CLAIMS. 16

17 2017 Conduent, Inc. All rights reserved. Conduent and Conduent Agile Star are trademarks of Conduent, Inc. and/or its subsidiaries in the United States and/or other countries. BRXXXX