TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Filing Medicare Primary Paper Claims > Crossover Claim Type 30 Instructions

   
 

6.14.1 Crossover Claim Type 30 TMHP Standardized MRAN Form

6.14.2 Crossover Claim Type 30 Instructions

Providers who bill professional services on the CMS-1500 paper claim form may submit the Crossover Claim Type 30 template with a copy of a completed claim form. All fields (excluding Medicaid information fields) on the form must be completed using the Remittance Advice or Remittance Notice received from Medicare. In addition, all details from the Medicare Remittance Advice/Remittance Notice must be included in the template, regardless if a deductible or coinsurance is due.

The TMHP Standardized MRAN Form must be typed or computer-generated. Handwritten TMHP Standardized MRAN Forms will not be accepted and will be returned to the provider.

The following are the requirements for the Crossover Claim Type 30 template:

Block No.
Field Description
Guidelines

1

NPI/API

Enter the NPI for the billing provider.

2

Medicare ID

Enter the Medicare Provider ID number of the billing provider listed on the Medicare Remittance Advice/Remittance Notice.

3

TPI

Enter the Medicaid TPI number of the billing provider.

4

Provider Name

Enter the billing provider's name.

5

Medicaid Client Number

Enter the patient's nine-digit Medicaid number from their Medicaid Identification form.

6

Client Last Name

Enter the patient's last name listed on the Medicare Remittance Advice/Remittance Notice.

7

Client First Name

Enter the patient's first name listed on the Medicare Remittance Advice/Remittance Notice.

8

Medicare Paid Date

Enter the Medicare Paid Date listed on the Medicare Remittance Advice/Remittance Notice.

9

Medicare ICN

Enter the Medicare ICN number listed on the Medicare Remittance Advice/Remittance Notice.

10

Patient HIC Number

Enter the patient's Medicare HIC number (Medicare Identification number) listed on the Medicare Remittance Advice/Remittance Notice.

11

From DOS

Enter the first date of service for each procedure in a MM/DD/YYYY format.

11

To DOS

Enter the last date of service for each procedure in a MM/DD/YYYY format.

11

POS

Enter the place of service (POS) listed on the Medicare Remittance Advice/Remittance Notice.

11

Units

Enter the number of units (quantity billed) from the Medicare Remittance Advice/Remittance Notice.

11

CPT

Enter the appropriate procedure code for each procedure/service listed on the Medicare Remittance Advice/Remittance Notice.

Note: Procedure code listed on the Standardized MRAN form may not match the procedure code listed on the claim form attached.

11

Mods

Enter the modifier (when applicable) listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Charges

Enter the Medicare charges (billed amount) listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Allow

Enter the Medicare allowed amount listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Ded

Enter the Medicare deductible amount listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Coins

Enter the Medicare Coinsurance amount listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Paid

Enter the Medicare paid amount listed on the Medicare Remittance Advice/Remittance Notice for each detail.

11

Reason Code

Enter Medicare's reason code listed on the Medicare Remittance Advice/Remittance Notice for each detail.

12

Total Charges

Enter the Medicare total charges (billed amount) listed on the Medicare Remittance Advice/Remittance Notice.

Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate "Continue" in this block.

12

Total Allow

Enter the Medicare total allowed amount listed on the Medicare Remittance Advice/Remittance Notice.

12

Total Ded

Enter the Medicare total deductible amount listed on the Medicare Remittance Advice/Remittance Notice.

12

Total Coins

Enter the Medicare total coinsurance amount listed on the Medicare Remittance Advice/Remittance Notice.

12

Total Paid

Enter the Medicare total paid amount listed on the Medicare Remittance Advice/Remittance Notice.

12

Total Reason Code

This field must be left blank.

13

Medicare Prev Paid

Enter the Medicare previous paid amount listed on the Medicare Remittance Advice/Remittance Notice.


Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
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