Web Portal Crossover ClaimSubmissions for COS 440 Providers

Objectives

The Purpose of this Webinar:

• Intro to Procedure Codes and Medicare Payment Rates

• Review the Process for Providers Submitting Crossover

Claims

• Timely Claims Filing and Adjustment Guidelines

NOTE:

This review is applicable to COS 440 providers

(agencies) that are enrolled as both Medicare and

Medicaid providers and serve members that are eligible

for both Medicaid and Medicare.

Once a Medicare claim crosses over to Medicaid, it may not be modified or

adjusted. Per Part I Policy, Claims billed to Medicaid must be billed in the same

manner as they are to Medicare. However, because Medicare does not

recognize the modifiers used in the COS 440 changes have been made in

GAMMIS to adapt the system to accommodate Medicare coding for COS 440

crossover claims.

Additionally, both DBHDD and DCH recognize the difference in rates paid by

Medicare and Medicaid for the same covered procedures. The departments

have worked together to revise how Crossover Claims (Claim Type B) process

and pay for COS 440 providers. The updated pricing logic utilizes weighted

practitioner-level blended rates based upon historical utilization trends across

COS 440.

Procedure Code and Medicare Payment Rate

New Professional Claim

2

1

Enter the required information and as much optional information as possible (all items denoted with an asterisk (*) are required fields)

Additional panels that will need to be completed prior to submitting claims.

• Diagnosis

• Other Payer Claims Data

• Detail

• Other Payer Information

• Other Payer Adjustment Information

Crossover Professional Billing Information(continued)

Diagnosis

Diagnosis(continued)

1. Click add to activate the diagnosis section for each additional diagnosis to be entered.

2. Enter the sequence (diagnosis code pointer) number.

3. Enter the diagnosis (to find a diagnosis code, use the [Search] feature).

32 1

Other Payer Claims Data

Select “Add” to indicate this is a crossover/ secondary claim and enter all information required.

Other Payer Claims Data(continued

• Claim Filing = Medicare Part B

• Relationship = Self

• Other Insured Identifier = Primary’s member ID number

• Payer Responsibility = Always Primary

• Payer Identifier = Primary’s ID number

• Insurance Company name = Name of primary Insurance

• Paid Date = Date the primary paid you

• Paid Amount = Total amount Paid for all line on this claim by primary

Other Payer Claims Data(continued)

Enter the required information and as much optional information as possible (all items

denoted with an asterisk (*) are required fields)

Detail

Detail(continued)

Enter the required information and as much optional information as possible (all items denoted

with an asterisk (*) are required fields)

Detail Other Payer Information

Detail Other Payer Information(continued)

Enter information on the Other Payer Information panel. This panel

allows you to tell us:

• The Primary’s Paid amount

• The Primary’s Paid date for your active line

• Payer ID

Detail Other Payer Adjustment Information

What is Due to be Paid as an adjustments indicated by primary

carrier

Adjustment Code 1 = Deductible

Adjustment Code 2 = Coinsurance

Detail Other Payer Information(continued)

Adjustment Code 1 = Deductible

Adjustment Code 2 = Coinsurance

Detail Other Payer Information(continued)

Review Detail Summary Information Section

Note: Double check your claim adjustment amount matches your EOB and no additional lines are

added in error

Submit Claim

Submit is located at the top of the

claim form

Timely SubmissionFor most providers, timely filing is six months from the month the service was rendered by the provider, however, there are exceptions:

• Claim adjustment: Within three months of the month of payment

• Claim resubmission: Within three months of the month the denial occurred

• Crossover claim: Within 12 months of MOS

• Secondary (COB/TPL) claim: Within 12 months of MOS

IN SUMMARY: COS 440 providers that are also enrolled Medicare providers will

continue to submit crossover claims for members covered by both Medicaid and

Medicare with codes listed above but with

A. ONLY the modifiers allowable by CMS for Medicare claims; or

B. no modifiers at all.

Claims will crossover to Medicaid as they currently do but will pay at the

assigned blended rate or less. This pricing logic will be applicable ONLY to

COS 440 Crossover claims and (barring any Third Party Liability/other

insurance payments) will be the only payment providers will receive.

Implementation of this new pricing logic is April 1, 2017. The

new pricing logic will only affect claims with a date of service of

4/1/2017 or after.

Additionally, DCH would like to remind providers of the policy outlined in the

PART I Policies and Procedures for Medicaid/PeachCare for Kids Manual;

Chapter 300; Section 302; Subsection 302 which states: “PLEASE NOTE:

When billing either Medicare FFS or Medicare Advantage Plan, you must

bill Medicaid in the same manner in which you submitted the bill to

Medicare.”

Closing Questions

and Answers