Wis. ForwardHealth Online Handbook, Hospice, Topic #671

A Medicare crossover claim is a Medicare-allowed claim for a dual eligible or QMB-Only (Qualified Medicare Beneficiary-Only)

member sent to ForwardHealth for payment of coinsurance, copay, and deductible.

Submit Medicare claims first, as appropriate, to one of the following:

• Medicare Part A fiscal intermediary

• Medicare Part B carrier

• Medicare DME (durable medical equipment) regional carrier

• Medicare Advantage Plan or Medicare Cost Plan

• Railroad Retirement Board carrier (also known as the Railroad Medicare carrier)

There are two types of crossover claims based on who submits them:

• Automatic crossover claims

• Provider-submitted crossover claims

Automatic Crossover Claims

An automatic crossover claim is a claim that Medicare automatically forwards to ForwardHealth by the COBC (Coordination of

Benefits Contractor).

Claims will be forwarded if the following occur:

• Medicare has identified that the services were provided to a dual eligible or a QMB-Only member.

• The claim is for a member who is not enrolled in a Medicare Advantage Plan.

Providers are advised to wait 30 days before billing for claims submitted to Medicare to allow time for the automatic crossover

process to complete. If automatic crossover claims do not appear on the ForwardHealth and/or the MCO (managed care

organization)'s RA (Remittance Advice) after 30 days of the Medicare processing date, providers are required to resubmit the

claim directly to ForwardHealth or the MCO using the NPI (National Provider Identifier) that was reported to ForwardHealth as

the primary NPI.

If the service is covered by the MCO, the ForwardHealth RA will indicate EOB (Explanation of Benefits) code 0287 (Member is

enrolled in a State-contracted managed care program). If the service is covered on a fee-for-service basis, the MCO RA will

indicate that the service is not covered. If the crossover claim is submitted without error, the responsible entity (either

ForwardHealth or the MCO) will process the claim to a payable status.

Provider-Submitted Crossover Claims

A provider-submitted crossover claim is a Medicare-allowed claim that a provider directly submits to ForwardHealth when the

Medicare claim did not automatically cross over. Providers should submit a provider-submitted crossover claim in the following

situations:

• The automatic crossover claim does not appear on the ForwardHealth or MCO RA within 30 days of the Medicare

processing date.

• The automatic crossover claim is denied, and additional information may allow payment.

• The claim is for a member who was not enrolled in BadgerCare Plus or Wisconsin Medicaid at the time the service was

submitted to Medicare for payment, but the member was retroactively determined enrolled in BadgerCare Plus or

Medicaid.

• The claim is for a member who is enrolled in a Medicare Advantage Plan or Medicare Cost Plan.

• The claim is for a member who is enrolled in Medicare and commercial health insurance that is secondary to Medicare (for

example, Medicare Supplemental).

When submitting crossover claims directly, the following additional data may be required on the claim to identify the billing and

rendering provider:

• The NPI that ForwardHealth has on file for the provider

• The taxonomy code that ForwardHealth has on file for the provider

• The ZIP+4 code that corresponds to the practice location address on file with ForwardHealth

Providers may initiate a provider-submitted claim in one of the following ways:

• DDE (Direct Data Entry) through the ForwardHealth Provider Portal

• 837I (837 Health Care Claim: Institutional) transaction, as applicable

• 837P (837 Health Care Claim: Professional) transaction, as applicable

• PES (Provider Electronic Solutions) software

• Paper claim form