Jane Dotson
Medicare crossover claims refer to the process where a Medicare insurance holder is also eligible for another benefit, allowing Medicare to transfer processed claim information to other insurance companies. This typically occurs when Medicare is the primary payer, paying up to the limits of its coverage, and then sending the remaining balance to the secondary payer. In the case of dual eligibility with Medicare and Medicaid, Medicare pays a portion of the claim, and the remaining deductible, co-pays, and coinsurance are billed to Medicaid.
| Characteristics | Values |
|---|---|
| Definition | Crossover claims, commonly known as Medicare crossover claims, happen when a Medicare insurance holder is also eligible for another benefit. |
| Who is eligible? | People with Medicare and Medicaid are known as dual eligibles and account for about 20% of Medicare beneficiaries (12.1 million people). |
| Primary and secondary payers | Medicare is the primary payer and pays up to the limits of its coverage. The remaining balance is sent to the secondary payer. |
| Process | Medicare transfers processed claim information to Medicaid or other insurance companies. |
| Benefits | There is no need to bill Medicaid or any other secondary insurance company separately for the remaining amount. |
| Submission | Submit claims to your Medicare carrier when Medicare is primary, and the other insurance is secondary. |
| Conditional payment | If the insurance company doesn't pay the claim promptly (usually within 120 days), Medicare may make a conditional payment to pay the bill and then later recover any payments the primary payer should've made. |
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What You'll Learn
Medicare and Medicaid: dual eligibility
Medicare and Medicaid are both health insurance programs, but each serves a different purpose. Medicare is a federal program that provides health insurance to people aged 65 and over, as well as some younger people with disabilities. On the other hand, Medicaid is a joint federal and state program that helps cover medical costs for certain low-income individuals, families, children, pregnant women, the elderly, and people with disabilities.
In some cases, individuals may be eligible for both Medicare and Medicaid, which is known as "dual eligibility". This typically occurs when an individual has limited income and resources, but their income may be too high to qualify for Medicaid alone. In such cases, Medicare will usually be the primary payer, covering the costs up to the limits of its coverage, and then Medicaid will act as the secondary payer, covering any remaining balance.
To ensure proper coordination of benefits, it is important for individuals with dual eligibility to inform their doctors and healthcare providers about their Medicare and Medicaid coverage. This is because the coordination of benefits between Medicare and Medicaid can be complex, and the order in which the claims are paid can vary depending on the specific circumstances. In some cases, Medicare may make a conditional payment and then recover any payments that should have been made by the primary payer.
For individuals with dual eligibility, Medicare Crossover Claim Submissions facilitate the processing of claims between Medicare and Medicaid. This process ensures that claims submitted to Medicare are crossed over to the secondary payer, such as Blue Cross and Blue Shield of Texas, after being processed by the Medicare intermediary. It is important to note that incorrect payments may be made if the Home Plan receives a Medicare Primary claim before it is crossed over, and such payments should be based on the actual Explanation of Medicare Benefits (EOMB) rather than an estimated one.
While Medicare and Medicaid work together to provide coverage for eligible individuals, it is important to understand the specific rules and regulations that govern each program. The eligibility criteria for Medicaid vary by state, and individuals must meet their state's rules for income, resources, and residency. Additionally, Medicaid offers benefits that are not typically covered by Medicare, such as nursing home care and personal care services. By understanding the differences between these programs and how they interact, individuals can effectively navigate their healthcare options and ensure they receive the coverage they need.
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Medicare as the primary payer
If you have Medicare and another form of health insurance, each type of coverage is called a "payer". The "primary payer" pays up to the limit of its coverage and then sends the remaining balance to the "secondary payer". Medicare is often the primary payer, meaning it pays first, and another insurance plan covers the rest. This is called "coordination of benefits".
Medicare can work with other insurance plans to cover healthcare costs and services. When you are enrolled in benefits, Medicare will act as the primary payer and cover most of your costs. Your other health insurance plan will then act as the secondary payer and cover any remaining costs, such as copayments or coinsurance.
Medigap and Medicare Supplemental claims can be routed directly from Medicare to a secondary payer, such as Blue Cross and Blue Shield of Texas (BCBSTX). This is known as the CMS crossover process. When claims are submitted to Medicare, they will be crossed over to the secondary payer after being processed by the Medicare intermediary.
In some cases, Medicare may not be the primary payer. For example, if you are using Medicare alongside workers' compensation, the latter always pays first. This is because workers' compensation is an agreement that your employer will pay for any medical costs if you are injured at work, in return for you agreeing not to sue them for damages. If you are a veteran, TRICARE will be the primary payer for services not covered by Medicare.
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Secondary payers and supplemental benefits
When Medicare was introduced in 1966, it was the primary payer for all claims except for those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran’s Administration (VA) benefits. However, in 1980, legislation was passed that made Medicare the secondary payer to specific primary plans, shifting costs from Medicare to private sources of payment.
The "primary payer" pays up to the limits of its coverage and then sends the remaining balance to the "secondary payer". If the "secondary payer" does not cover the remaining balance, the patient may be responsible for the remaining costs. Medicare may be the secondary payer when beneficiaries have other health insurance or coverage, such as a group health plan, retiree coverage, or Medicaid. In some cases, Medicare may make a conditional payment to pay the bill and then recover any payments the primary payer should have made.
It is important to understand the coordination of benefits when dealing with multiple payers. For example, if an individual has Medicare and is covered by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), COBRA will pay primary, and Medicare will pay secondary during the 30-month coordination period for End-Stage Renal Disease (ESRD). Similarly, if an individual is aged 65 or older, covered by Medicare, and has COBRA coverage, Medicare will pay primary, and COBRA will pay secondary.
When seeking medical care, it is essential to inform your doctor and other healthcare providers about any changes in your insurance coverage. This includes disclosing if you have coverage in addition to Medicare, such as group health coverage, worker's compensation, or no-fault or liability insurance. This information helps ensure that your bills are sent to the correct payer and avoids delays in payment processing.
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Claims submission and crossover payments
When it comes to claims submission and crossover payments, there are a few key things to keep in mind. Firstly, it's important to understand the concept of "payers". If you have Medicare and other health insurance, each type of coverage is considered a separate "payer". The "primary payer" will pay up to the limits of its coverage and then send the remaining balance to the "secondary payer".
When submitting claims, it's important to follow the correct process. Claims should be submitted to your Medicare carrier when Medicare is the primary payer and the other insurance is secondary. After the claim has been processed by the Medicare intermediary, it will be crossed over to the secondary payer. This process can take around 14 business days. It's important to avoid submitting duplicate claims, as this can cause issues with cost-sharing calculations.
In some cases, Medicare may make a conditional payment if the primary payer does not pay the claim promptly (usually within 120 days). Medicare can then recover any payments that the primary payer should have made. Additionally, it's important to note that Medicare crossover information should only be entered for claims that were billed to Medicare first. This information can be entered through the Provider Web Portal, following specific steps depending on the claim type.
For Blue Cross and Blue Shield Plans, the Centers for Medicare and Medicaid Services (CMS) crossover process is utilised. This process routes Medicare Supplemental claims directly from Medicare to the insurer. Providers do not need to submit claims to the insurer separately. However, it's crucial to ensure that payments are based on the actual Explanation of Medicare Benefits (EOMB) rather than an estimated one to avoid incorrect payments.
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Contacting Medicare for more information
If you have questions about Medicare and other insurance policies, you can contact Medicare in several ways. For specific billing questions and questions about your claims, medical records, or expenses, log into your secure Medicare account, or call 1-800-MEDICARE. If you want Medicare to share your personal information with someone other than yourself, you must fill out an "Authorization to Disclose Personal Health Information" form.
You can also contact your state to find Medicare Savings Programs that can lower your Medicare costs, apply for Extra Help with Medicare drug costs, and get information about how to apply for Medicaid. State Health Insurance Assistance Programs (SHIPs) can also help you choose a plan, review coverage, understand costs, apply for extra help, file a complaint or appeal, and make informed Medicare decisions.
If you have questions about who pays first or if your coverage changes, call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
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Frequently asked questions
Medicare crossover claims occur when a Medicare insurance holder is also eligible for another benefit, such as Medicaid. In these cases, Medicare is the primary payer and pays up to the limits of its coverage, then sends the remaining balance to the secondary payer.
You should submit accurate medical claims with the latest codes to Medicare for a successful crossover. Claims submitted to Medicare will be crossed over to the secondary payer after they have been processed by the Medicare intermediary.
You can contact Medicare.gov or 1-800-Medicare to get information on all available options. You can also call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627) if you have questions about which payer is primary or secondary, or if your coverage changes.
