Changes to the Mandatory Medigap ("Claim-Based") Crossover Process
The Centers for Medicare & Medicaid Services’ (CMS) Coordination of Benefits Contractor (COBC) has assumed responsibility for the Medigap claim-based crossover, which is driven by information that participating providers enter on the incoming claim, effective October 1, 2007. For crossover purposes a new five-digit Medigap identifier (ID) is assigned to those secondary insurers who have elected claim-based crossover. Providers may reference a listing of the assigned COBA Medigap claim-based IDs on CMS’ Coordination of Benefits Web site at: http://www.cms.hhs.gov/COBAgreement/Downloads/Medigap Claim-based COBA IDs for Billing Purpose.pdf
Participating providers that wish to trigger crossovers to Medigap insurers will be required to include that new identifier, as found on the CMS COB Web site, on their incoming Medicare claims. Failure to do so will result in their claims not being successfully crossed over to the Medigap insurer. If the older contractor-assigned number is included on the claim, Medicare will include the standard MA19 message—“Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.”—on the provider’s electronic remittance advice (ERA) or other production remittance advice for the associated claim(s). Participating providers that are permitted under Administrative Simplification Compliance Act (ASCA) to bill Medicare on paper should include the newly assigned five-digit COBA Medigap claim-based ID within Item 9-D of the CMS-1500 claim form. Providers that are required to bill Medicare electronically using the Health Insurance Portability and Accountability Act (HIPAA) American National Standards Institute (ANSI) X12-N 837 professional claim shall include the newly assigned five-byte only COBA Medigap claim-based ID (range=55000 to 59999) left-justified in field NM109 of the NM1 segment within the 2330B loop and followed by spaces.(See important note that follows regarding the submission of claims to Durable Medical Equipment Medicare Administrative Contractors [DME MACs].) Retail pharmacies that bill National Council for Prescription Drug Programs (NCPDP) batch claims to Medicare shall include the newly assigned Medigap identifier left-justified within field 301-C1 of the T04 segment of their incoming NCPDP claims and followed by spaces.
Providers should notify their clearinghouses and billing vendors of the changes to the Medigap claim-based crossover process as soon as possible.
Providers may obtain further clarification of the Medigap claim process at:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0743.pdf
