What is a crossover claim?
A Medicare crossover is a claim that Medicare sends to another insurer for secondary payment, after Medicare has processed the claim as the primary insurer. When a person has Medicare as their primary insurance, and also has secondary coverage, the medical provider typically only needs to send the claim to Medicare instead of sending it to both health plans. Medicare will facilitate sending the claim to the secondary insurer, via the crossover process.
When a Medicare beneficiary is a dual eligible – meaning they have Medicare and Medicaid – Medicare will process the claim first and then send it to Medicaid via the crossover process. Medicaid will then cover the cost-sharing (deductibles, co-pays and coinsurance) that’s left over after Medicare has paid its share.
Claims can also cross over from Medicare to Medigap plans, which pay for Original Medicare deductibles, co-pays, and coinsurance.
The crossover process is facilitated by the Centers for Medicare & Medicaid Services’ (CMS) Benefits Coordination and Recovery Center (BCRC) and the Coordination of Benefits Agreement (COBA) program. Under the COBA program, there’s a standardized, nationwide process for transmitting coverage information and Medicare paid claims data between the BCRC and secondary payers.
Do all Medicare claims use the crossover process if the enrollee has other health coverage?
The crossover process is only used if Medicare is the primary payer. Medicare is secondary when an enrollee also has active employee coverage from an employer that has at least 20 employees (or at least 100 employees if the enrollee is disabled). In that case, the claim needs to be sent to the primary payer first, rather than directly to Medicare.
And even when Medicare is the primary payer, the crossover process can only be used for private secondary coverage if there’s an agreement in place between the BCRC and the private insurer. If there isn’t, the BCRC can’t automatically cross over the claim. In that case, the Medicare beneficiary has to arrange for the secondary payer to receive the claim after Medicare has processed the claim.
