HIPAA training

OHCA Crossover Claims Requirements

It is important to remember that providers must include the correct Medicare identification number for a claim to crossover automatically. The following information concerns crossover claims:

  • If a provider does not receive the OHCA payment within 60 days of the Medicare payment, claims that did not crossover should be submitted electronically.
  • If the member has a Medicare supplement policy, proof of filing with the Medicare supplement carrier as well as Medicare must be submitted with the OHCA claim or the claim will deny.
  • If the member has a Medicare supplement policy, the claim is filed with Medicare and automatically crosses over to the Medicare supplement carrier rather than the OHCA for payment of coinsurance and deductible. After the provider receives all EOBs, the provider must submit the claim and EOBs to OHCA.

If the TPL benefit code has been entered incorrectly as a hospitalization (A) or medical (C) versus Medicare Supplemental Part A (O) or Medicare Supplemental Part B (P) for the supplemental policy, the claim crosses directly to the OHCA and may be paid without proof of filing with the Medicare supplement carrier.

These situations generally result in OHCA overpayments that must be refunded immediately. To prevent overpayment, a provider that identifies enrollees with a Medicare supplemental policy conveyed as an A or B on EVS can request a TPL file update by sending a copy of the enrollee’s Medicare supplemental insurance card to the TPL Unit.

Providers whose claims are not crossing over automatically should contact Provider Enrollment to verify that OHCA has your Medicare provider number correctly in the system.

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