WHAT CLAIMS WILL CROSS OVER
Q1. Will all Medicare claims be crossed over to Michigan Medicaid?
Q2: Which Medicare claims will be crossed over to Michigan Medicaid?
A2: Michigan Medicaid is initially accepting only Medicare Part B professional claims from Wisconsin Physician Service (WPS).
Q3: Are there any claims excluded from the crossover process between WPS and Michigan Medicaid?
A.A3: Yes. The following types of claims will be excluded (not sent to Michigan Medicaid from WPS) from the crossover process:
• Totally denied claims;
• Claims denied as duplicates or for missing information;
• Adjustment claims (referred to as “replacement or void/cancel claims”);
• Claims reimbursed at 100 percent from WPS;
• Claims for dates of services outside the beneficiary’s Medicaid eligibility begin and end dates.
.Q4: Will non-physician practitioner (e.g., PA, nurse practitioner, nurse mid-wife, psychologist, social worker, etc.) claims be crossed over to Michigan Medicaid?
.A4: Yes. If the practitioner is directly enrolled in Michigan Medicaid, submit that Medicaid provider ID on the claim to WPS. Otherwise, the supervising physician/medical clinic Medicaid provider ID must be reported. (See C.Q1 & C.A1 for more information) WPS will pass this information on to Michigan Medicaid and it will be the basis of identifying the provider for purposes of Michigan Medicaid claims processing.
.Q5: Which claims will NOT be crossed over to Michigan Medicaid?
.A5: Claims processed by any Part B carrier other than WPS, a DMERC carrier, or any Part A claim will not be crossed over to Michigan Medicaid at this time. These claims must continue to be sent directly to Michigan Medicaid.
.Q6: Will DMERC and Part A claims be crossed over?
A.A6: Not at this time; providers will be notified when this will occur.
.Q7: Will hospital inpatient or outpatient Part B claims be crossed over to Michigan Medicaid? (New 10-04)
A.A7: No. Michigan Medicaid is initially accepting only Medicare Part B professional claims from WPS.
.Q8: Will a HCFA 1500 paper claim sent to WPS be crossed over?
A.A8: HCFA 1500 paper claims sent to WPS will be sent to Michigan Medicaid in the HIPAA mandated 837 4010A1 format. There is no way to report the Medicaid provider ID on a paper claim submitted to WPS. Michigan Medicaid cannot process a crossover claim without the Medicaid provider ID. If you submit a paper claim to WPS, you will have to directly submit a claim to Michigan Medicaid after receiving the remittance advice from WPS. (Rev. 10-04)
.Q9: Will a claim for a recipient who has Medicare, other insurance, and Medicaid be crossed over to all payers?
A.A9: No. Claims that include a secondary payer other than Michigan Medicaid may be crossed over to the secondary payer, but not to Michigan Medicaid. Once a remittance advice or explanation of benefits (EOB) is received from the secondary payer, the claim can be submitted directly to Michigan Medicaid, with the updated Medicare and other insurer payment and/or adjudication information.
Q10: Will claims where Medicare is the secondary payer and Michigan Medicaid is the tertiary payer be crossed over?
A.A10: Yes. If Michigan Medicaid is identified as the only other payer following Medicare, the Part B claims should be crossed over from WPS.
MEDICARE – MEDICAID NURSING FACILITY CROSSOVER CLAIMS WITH GROUP HEALTH INCORPORATED (GHI) (COORDINATION OF BENEFITS) – Facility billing guide
MDHHS accepts institutional crossover claims from the Coordination of Benefits Contractor, Group Health Incorporated (GHI).
The institutional nursing facility crossover claim process allows nursing facilities to submit a single claim for residents dually eligible for Medicare and Medicaid. After processing the Medicare portion, GHI forwards the claim to Michigan Medicaid for processing and reimbursement. A remittance advice (RA) is generated from Medicare with the details of the Medicare payment and Remark Code MA07 (the claim information has also been forwarded to Medicaid for review). If this remark code does not appear on the Medicare RA, a separate claim must be submitted to MDHHS. Once Medicare payment is received by the facility and Remark Code MA07 appears on the Medicare RA, the claim should appear on the Medicaid RA within 30 days. The facility may check claim status online through CHAMPS. If the claim does not appear in CHAMPS within 30 days, a claim should be submitted directly to MDHHS showing all Medicare payment information.
Providers must resolve denied claims with Medicare when there is a denied Medicare service not covered by Medicaid. The excluded Medicare service covered by Medicaid should be billed directly to Medicaid.
The following claims are excluded from the crossover process:
* Original Medicare claims paid in full without deductible or co-insurance remaining
* Claims with private and commercial insurance
* Adjustment claims fully paid without deductible or co-insurance
* Original Medicare claims paid at greater than 100% of submitted charges without deductible or co-insurance remaining
* 100% denied original claims
* 100% denied adjustment claims, with no additional beneficiary liability
* 100% denied original claims, with additional beneficiary liability
* 100% denied adjustment claims, with additional beneficiary liability
* Adjustment claims
* Mass adjustment claims – other (monetary or non-monetary)
* Medicare secondary payer cost-avoided (fully denied) claims
* Claims reporting Revenue Code 0160 (Medicaid Reimbursement for a Nursing Facility Bed Following a Qualifying Medicare Hospital Stay)
* For any Medicare Part B services associated with this nursing facility claim, the facility would bill Medicare accordingly.
* Nursing facilities must continue to complete their claims as they have been doing for Medicare.
* Nursing facilities must report the beneficiary’s patient-pay, any offset to the patient-pay amount, and voluntary payments on the claim submitted to Medicare.
* When reporting ancillary services, the facility must indicate the service date on the line level of the claim. (Refer to applicable subsections in this chapter for additional information regarding ancillary services.)
For patients treated in the inpatient setting with either Medicare Part A coverage or Medicare Part B coverage, no reimbursement is made for capital.
Prior to final settlement, hospitals must identify claims eligible to receive capital costs as a result of the patient’s Medicare Part A benefits being exhausted. A copy of the Medicaid invoice and the Medicaid Remittance Advice (RA) page showing approval must be provided for these claims. The hospital must also provide a copy of the Medicare Explanation of Benefits (EOB) showing that the patient’s Part A benefits have been exhausted. Failure by the hospital to provide this information results in these claims being excluded from its final settlement.
For patients with Medicare Part B coverage and no Medicare Part A coverage, the Medicaid payment amount is determined by subtracting the Medicare Part B payment from the Medicaid inpatient amount that would otherwise be approved (either under DRG or per diem).
For patients with Medicare Part A coverage, the Medicare payment is compared to the Medicaid inpatient amount that would otherwise be approved (either under DRG or per diem).
* If the Medicare amount is greater, no additional payment is made, even though a coinsurance or deductible amount may be
* If the Medicaid amount is greater, the difference is paid, up to a maximum of the Medicare coinsurance and deductible amounts due for the claim. If a beneficiary is in a Medicare Advantage Plan, Medicaid’s liability never exceeds that of the beneficiary. In addition, if the provider accepts the payment from the Medicare Advantage Plan as payment in full, Medicaid has no further liability.