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A Medicare crossover claim is a claim that Medicare sends to another insurer for secondary payment.
If a Medicare beneficiary has dual eligibility (having both Medicare and Medicaid), the Medicare claims will cross over to Medicaid. This covers the Medicare cost share (i.e., deductibles, co-pays, coinsurance).
Medicare beneficiaries with supplemental insurance, such as Medigap, can have their provider report the Medigap claim information to Medicare who will automatically advise the Medigap insurer of Medicare’s approved amount and payment. This eliminates the need for a separate bill to the Medigap insurer and reduce payment delays.
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Medigap electronic claims
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Medigap paper claims
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Item
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837 Version 5010
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CMS 1500 claim form
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Group policy number
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2320 Loop SBR 03
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Item 9a
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Medigap insurer ID code
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2330B Loop NM1 09
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Item 9d
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Release of information indicator
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2320 Loop OI 06
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N/A
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HealthChoice participates in the Coordination of Benefits Agreement (COBA) Medicare claims crossover program for Medicare beneficiaries who also have a HealthChoice plan. Enrollee eligibility and adjudicated claim data for claim coordination is transmitted to supplemental payers.
Medicare automatically crosses over patients’ HealthChoice claims to process as secondary.
If Medicare is the secondary payer, follow the CMS instructions for Medicare secondary payer (MSP). Submitting the member policy and group number on the claim is required. Use these group numbers when submitting claims:
- 76415077 HealthChoice.
- 76415170 Oklahoma DOC.
- 76415171 Oklahoma DRS.
Reducing Medicare COB payment delays.
- Ask patients if they have secondary insurance and confirm which plan is primary. If the member has dual plans with DRS as one of their plans, DRS is always the plan of last resort.
- Verify Medicare beneficiary status:
- Medicare Administrative Contractors (MACs) are contractors that process enrollment and claims for Medicare providers. Each MAC offers its own online provider portal for Medicare providers in its jurisdiction. To register with their MAC’s provider portal, providers can contact their MAC or access their MAC through the MAC provider portal. Each MAC also has its own automated phone system. Find the phone number for your MAC by viewing the list of MAC websites on the MAC provider portal and locate the MAC that covers your state.
- Work with your EDI clearinghouse, software vendor or billing agency to receive HIPAA compliant transactions (270 eligibility request). The EDI payer IDs are 71064 for HealthChoice and 71065 for DOC and DRS.
For questions, call Customer Care at toll-free 800-323-4314. TTY users call 711.
Future fee schedule updates for services by HealthChoice network providers are scheduled for:
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Annual Fee Schedule Releases
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Jan. 1
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April 1
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July 1
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Oct. 1
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Anesthesia (ASA)
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Comp
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Bariatric Surgery - Inpatient
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Comp
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A/C/D
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A/C/D
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A/C/D
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Bariatric Surgery - Outpatient
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Comp
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A/C/D
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A/C/D
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A/C/D
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Dental (ADA)
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Comp
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A/C/D
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A/C/D
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A/C/D
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Diabetes Prevention Program (DPP)
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Comp
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Endodontic
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Comp
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A/C/D
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A/C/D
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A/C/D
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HCPCS
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A/C/D
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Comp
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A/C/D
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A/C/D
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MS-DRG
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Comp
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MS-DRG LTCH
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Comp
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NDC
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Comp
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Comp
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Comp
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Comp
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Outpatient (w/ASC,ASC Implants, and Non-CMS Certified)
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Comp
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Comp
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Comp
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Comp
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Outpatient Revenue
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Comp
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A/C/D
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A/C/D
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A/C/D
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Preventive Services
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Comp
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A/C/D
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A/C/D
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A/C/D
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Professional (CPT and HCPCS)
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A/C/D
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Comp
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A/C/D
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A/C/D
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Select Inpatient (MS-DRG)
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A/C/D
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A/C/D
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A/C/D
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A/C/D
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Select Outpatient/ASC
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A/C/D
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A/C/D
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A/C/D
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A/C/D
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| Comp = Comprehensive; A/C/D = Adds, changes, deletes and other necessary updates |
As a reminder, national medical and dental associations may change, add, correct or delete billing codes throughout the year. When that occurs, EGID reviews the modifications as quickly as possible and makes any necessary updates. Additionally, EGID performs fee schedule updates on an ad hoc basis when necessary.
The EGID tiers were created in part to help support the continued existence and financial viability of truly rural hospitals. EGID’s tier designation process is intended to only recognize a rural reimbursement methodology if the urban or rural status is based on the ZIP code of the hospital and the status of that ZIP code in the U.S. Census Bureau’s metropolitan core-based statistical area.
Inpatient and outpatient tier designations and facility urban/rural designations are updated annually on Oct. 1. These designations are determined by the most current Centers for Medicare & Medicaid Services fiscal year inpatient prospective payment system impact file or the facility's ZIP code, included in the U.S. Census Bureau's metropolitan core-based statistical area. On Jan. 1, the urban/rural indicators are updated based on the most recent CMS ZIP code to carrier locality file for all facilities that are not hospitals.
For the most part, the applicable urban tier status is based on the most current CMS fiscal year inpatient prospective payment system impact file for network providers, unless the ZIP code of its physical location is included in the U.S. Census Bureau’s metropolitan core-based statistical area.
Inpatient and outpatient tier designations are defined as:
- Tier 1 – Network urban facilities with greater than 300 beds.
- Tier 2 – All other urban and non-network facilities.
- Tier 3 – Critical access hospitals, sole community hospitals, and Indian, military and VA facilities.
- Tier 4 – All other network rural facilities.
- Tier 6 – Outpatient rural emergency hospitals.
Fee schedule updates are reported in each quarterly issue of the Network News. If you need specific codes
and allowable fees affected by these updates, please view or download the latest fee schedule. The fee schedule has not been publicly disclosed and is deemed confidential pursuant to 51 O.S. and should not be disseminated, distributed or copied to persons not authorized to receive the information.
For more information, email EGID Network Management or call 405-717-8790 or toll-free 844-804-2642. TTY
users call 711.
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