Tuesday, October 27, 2009

Roll-Over/Cross-Over for Secondary and Tertiary Billing


Medicare currently has contractual arrangements with supplemental insurers to automatically crossover claims payment information for their policyholders. An eligibility file furnished by the supplemental insurer is used to drive the process rather than information found on the claim. These eligibility files are matched, based on the Health Insurance Claim (HIC) number, against Medicare’s internal eligibility file. If a match occurs, the beneficiary’s record is flagged indicating to which company we will cross claim payment information.

The name of the crossover insurance company will appear on both the beneficiary Explanation of Medicare Benefits and the provider’s Remittance Notice.

Users need to ensure the crossover payment was forwarded to the correct secondary payer by reviewing the remittance advice.

Each supplemental insurer is given the opportunity to specify criteria related to the claims the insurer wants Medicare to crossover. Examples of claims most often excluded from the crossover process:
· Totally denied claims
· Claims denied as a duplicate or for missing information
· Adjustment claims
· Claims reimbursed at 100%
· Claims for dates of service outside of the supplemental policy’s effective and end dates.

As part of the CMS process, it is required for each service furnished by the provider that the provider reports each service as a separate line item on the claim form.
As claims are processed, the beneficiary’s eligibility record is checked by the system to determine whether the claim should be considered for crossover. If the beneficiary’s eligibility record is flagged for crossover, the claim is then checked by the system to determine whether the claim meets the crossover criteria required by the insurer. If the claim is not excluded, at this point it is marked for crossover to the appropriate company. An electronic claims payment record is then created and forwarded to the requesting insurer. This eliminates the need for the billing office to file claims for the patient’s supplemental benefits.

Upon receipt of the transmittal crossover file, the system will initially edit the file and return a flat file to the contractor indicating the number of claims received and accepted. The entire file that contains any transmission error will be returned with a request for retransmission.
In regard to crossovers, Medicare cannot add, change, or delete any eligibility information furnished by an insurer. In addition, the crossover process is totally automatic, and does not require or permit any clerical intervention.

The crossover insurance companies send an eligibility tape at least once a month to the primary insurer. The crossover company’s eligibility tape reads the internal eligibility record and looks for the HIC matches.

The Medicaid update process is the same as the automatic crossover process except the eligibility tape is sent to the primary insurer by each state.

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