HCA-28: Medicare

HCA-28: Medicare-Medicaid Crossover Invoice Form – Inpatient Claims Special Batch Processing ONLY

The Medicare-Medicaid Crossover Invoice form (HCA-28) should be used when submitting Inpatient crossover claims for Special Processing ONLY. Use this form as a supplement to the Medicare Explanation of Benefit (EOB) statement attachment previously required on paper crossover claims.

The form was created due to multiple versions of the Medicare (EOB) statements being printed from the different software formats currently available. The information to be keyed from the Medicare EOB to process crossover claims no longer appears in a standard format when printed. This means the necessary information to be keyed appears differently and is marked with different headers on each printed electronic Medicare EOB, making crossover claim processing challenging.

The Medicare-Medicaid Crossover Invoice form will allow these claim types to be keyed more quickly and accurately.

  1. Write CROSSOVER at the top of every claim.
  2. Use this form for Inpatient claims when filing a special process claim, using the HCA 17 Claim Inquiry Response Form.
  3. Use one Medicare-Medicaid Crossover invoice for each claim.
  4. Mail the completed form to: Gainwell Technologies P.O. Box 18506 Oklahoma City, OK 73154.

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