Which of the following describes the term crossover as it relates to Medicare?

Last updated: 10/04/2022

This Quick Guide covers when and how to enter other insurance information (Third-Party Liability) or Medicare crossover information.

Other insurance information should be entered on claims with Third-Party Liability (TPL)/commercial insurance. For claims billed to Medicare, provide the Medicare crossover information (see description below).

Medicare crossover information should be entered on any claim that was billed to Medicare first. The term "Crossover claim" may refer to a claim that is directly from Medicare (and has since "crossed over" to Health First Colorado [Colorado's Medicaid Program] for processing) or a provider-initiated claim (submitted via the Provider Web Portal, batch or paper) that contains Medicare claim information. A crossover claim does not necessarily have to come directly from Medicare. Medicare Health Maintenance Organization (HMO) Co-pays should be treated like original Medicare Coinsurance. Enter the total of Medicare Coinsurance + Medicare Co-pay amount into the Co-insurance Amount field under the Medicare Crossover Details section of the claim.

From the list below, identify the example below which most closely matches your claim, then proceed to the appropriate page for instructions. The sample screens shown in this guide may vary depending on claim information.

The Billing Provider ID will be used for claims payment. If the Billing Provider ID is a National Provider Identifier (NPI), the Web Portal automatically selects the NPI that is effective on the "From Date" in the Service Details section or the from date of the "Covered Dates" in the Claim Information section and inserts that NPI into the "Billing Provider ID" field during Submit Claim: Step 3.

Completion of the Service Facility Provider ID/Service Facility Provider Location ID is conditional. If a provider has the same provider type for multiple enrolled, service locations, the provider should use the unique NPI in the Billing Provider ID field. The provider may use the unique NPI in the Service Facility ID field if they choose. If the NPI for the billing provider is different than the location where the service was rendered, the Service Facility ID/Service Facility Provider Location ID field must be completed.

• Entering Other Insurance Information on a Claim
  • Professional Claim with TPL
    • TPL Denied
    • TPL applied to deductible
  • Institutional Claim with TPL
• Entering Medicare Crossover Information on a Claim
  • Professional Claim with Medicare (Crossover)
  • Institutional Inpatient Claim with Medicare (Crossover)
  • Institutional Inpatient Claim with Medicare (Part B Only Crossover)
  • Institutional Outpatient Claim with Medicare (Crossover)

Professional Claim with TPL

1. On the Submit Professional Claim: Step 1 page, select "Professional" from the "Claim Type" drop-down, complete all applicable fields and then check the "Include Other Insurance" box under the Claim Information section. Click "Continue." If submitting a claim with Medicare crossover information, see the instructions in this guide.
   
   
2. On the Submit Professional Claim: Step 2 page under the Other Insurance Details section, click [+] to add new other insurance information.
   
   
3. Enter the insurance company name in the Existing Carrier field, then select the appropriate carrier from the drop-down list. If the carrier is not found, select Other Carrier and type the Carrier Name.
   
   
4. Enter the Policy Holder Last Name, First Name, Policy ID and Effective Dates (as applicable). Leave the Insurance Type field blank.
   
   
5. Select the payer responsibility from the drop-down list.

   Note: Health First Colorado is the payor of last resort.

   
6. Select the relationship of the covered individual to the responsible individual from the drop-down list.
   
   
7. Select the Claim Filing Indicator from the drop-down list, then click the "Add" button.
   
   
8. Review the next screen to ensure the other insurance information has been saved. If you are finished adding other insurance information, click "Continue." If you need to add more other insurance information, click + and repeat the applicable steps.
   
   
9. Proceed to the Submit Professional Claim: Step 3 page and complete all applicable fields. Click "Add," then repeat the process until all service detail lines have been added.
   Whether the TPL was paid or denied, you must enter a paid date.

TPL Denied

If the TPL was denied, enter "0.00" in the Paid Amount field and "1" in the Paid Units field.

Once complete, click "Submit."

TPL applied to deductible

When the TPL has applied the entire amount to patient responsibility, and a prior authorization is required for the service, the EOB from the TPL must be attached to the claim for verification.

Institutional Claim with TPL

1. On the Submit Institutional Claim: Step 1 page, select "Inpatient, Outpatient or Long-Term Care" from the "Claim Type" drop-down and complete all applicable fields.
   Check the "Include Other Insurance" box under the Claim Information section, then click "Continue."
   
   
2. On the Submit Institutional Claim: Step 2 page under the Other Insurance Details section, enter the insurance company name in the Existing Carrier field, then select the appropriate carrier from the drop-down list. If the carrier is not found, select Other Carrier and type the Carrier Name.
   
   
3. Enter the Policy Holder Last Name, First Name, Policy ID and Effective Dates.
   
   
4. Proceed to the Submit Institutional Claim: Step 3 page and complete all applicable fields. Click "Add," then repeat the process until all service detail lines have been added. Once complete, click "Submit."
   
   

Entering Medicare Crossover Information on a Claim

Professional Claim with Medicare (Crossover)

1. On the Submit Professional Claim: Step 1 page, select "Crossover Professional" from the "Claim Type" drop-down and complete all applicable fields under the Provider Information, Member Information and Claim Information sections. Do not check the "Include Other Insurance" box under the Claim Information section. Click "Continue."
   
   
2. Do not check the "Include Other Insurance" box.
3. On the Submit Professional Claim: Step 2 page, complete all applicable fields under the Diagnosis Codes section, then click "Add." Repeat until all diagnosis codes have been added, then click "Continue."
   
   
4. On the Submit Professional Claim: Step 3 page under the Medicare Crossover Details section, enter the associated Medicare crossover information for each service line. Click "Add" to repeat the process until all service detail lines have been added. Once complete, click "Submit."
   
   

Institutional Inpatient Claim with Medicare (Crossover)

1. On the Submit Institutional Claim: Step 1 page, select "Crossover Inpatient" from the "Claim Type" drop-down and complete all applicable fields under the Provider Information and Member Information sections.
   
   
2. Proceed to the Claim Information section and complete all applicable fields. Select the appropriate Facility Type Code from the drop-down list. Do not check the "Include Other Insurance" box under the Claim Information section.
   
   
3. Proceed to the Medicare Crossover Details section and complete all applicable fields, then click "Continue." See the next section for instructions on Part B Only Crossover.
   
   

Institutional Inpatient Claim with Medicare (Part B Only Crossover)

1. 1. Follow Steps 1 and 2 from the Institutional Inpatient Claim with Medicare (Crossover) section above. In the Medicare Crossover Details section, complete all applicable fields and select the Part B only/Part A Exhausted checkbox. Click "Continue".
   
   

Institutional Outpatient Claim with Medicare (Crossover)

1. On the Submit Institutional Claim: Step 1 page, select "Crossover Outpatient" from the "Claim Type" drop-down and complete all applicable fields. Do not check the "Include Other Insurance" box under the Claim Information section. Once complete, click "Continue."
   
   
2. Proceed to the Medicare Crossover Details section and complete all applicable fields, then click "Continue."
3. On the Submit Institutional Claim: Step 2 page, complete all applicable fields, then click "Add." Repeat the process as needed for each detail line. Once complete, click "Continue."
   
   
4. On the Submit Institutional Claim: Step 3 page, complete all applicable fields under the Service Details section. Enter the associated Medicare Crossover Details for each service line. Click "Add" to repeat the process until all service detail lines have been added. Click "Submit" once completed.
   
   

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