CMS Pub. 100-04, ch. 28, § 70

Insurance Policies

(Rev. 4069, Issued: 06-08–18, Effective: 07-09-18, Implementation: 07-09-18)

For applicable policy on information sharing, see Pub 100-1, the Medicare General Information, Eligibility

and Entitlement Manual, Chapter 6.

For applicable cost sharing policy, see Pub 100-06, the Medicare Financial Management Manual, Chapter 1.

Cost Calculation Process Leading Up to the BCRC’s Assumption of Claim-Based Medigap Crossovers

Up to and including the final claims transferred under their pre-existing mandatory Medigap (claim-based)

crossover processes (note: the “final” claims should be those processed by the A/B MAC (Part B) or DME

MAC just before the October 2007 release is installed), A/B MACs (Part B) and DME MACs should

determine the frequency at which they routinely transmit notices to all Medigap insurers but must transmit

not less often than monthly. (See §70.4)

Effective October 1, 2005, CMS fully consolidated the eligibility file-based claims crossover process, as it

relates to Medigap insurers and other commercial payers, under the BCRC. Refer to §70.6 and succeeding

sub-sections for A/B MAC (Part B) and DME MAC requirements and responsibilities relating to the

national Coordination of Benefits Agreement (COBA) consolidated crossover process. Refer to §70.6.4 for

all MAC requirements relating to the COBA Medigap claim-based crossover process, which was

inaugurated on October 1, 2007. (See also Pub.100-04 chapter 27 §80.7.)

Following crossover consolidation, all A/B MACs (Part B) and DME MACs shall continue to pursue

collection of unpaid debts from Medigap insurers and other existing trading partners, even after such entities

have been transitioned to the COBA process. Those MACs that maintained claim-based crossover

arrangements with Medigap insurers shall pursue collection of their invoices up through and including their

invoices for the final claims transfer to the Medigap entities. These invoices should have been issued no

later than one (1) month following the last claims transfer to the Medigap insurers.

Suppression of Sanctioned Provider Claims from Claim-Based Medigap Crossovers

Effective with April 2, 2007, all A/B MACs (Part B) and DME MACs shall suppress fully denied provider

sanctioned claims for their mandatory Medigap crossover process with Medigap insurers, as authorized by

§1842(h)(3)(B) of the Social Security Act and §4081(a)(B) of the Omnibus Budget Reconciliation Act of

1987 [Public Law 100-230].

NOTE: All A/B MACs (Part B) and DME MACs shall continue to suppress 100 percent paid and 100

percent denied claims from their mandatory Medigap crossovers, per previous CMS guidance.