TMPPM 2010 > Volume 1, General Information > Section 6: Claims Filing > Filing Medicare Primary Paper Claims > Crossover Claim Types 31 and 50 Instructions

   
 

6.14.3 Crossover Claim Types 31 and 50

6.14.4 Crossover Claim Types 31 and 50 Instructions

Providers who bill inpatient and outpatient crossover claims on a UB-04 CMS-1450 paper claim form may submit the Crossover Claim Types 31 and 50 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, 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 Types 31 and 50 template:

Field Description
Guidelines

Medicare Paid Date

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

Provider Name

Enter the billing provider's name.

NPI/API/TPI

Enter the NPI/API/TPI for the billing provider.

Note: NPI/TPI or API/TPI.

Medicare ID

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

Street Address

Enter the billing provider's street address.

City

Enter the billing provider's city.

State

Enter the billing provider's state.

ZIP

Enter the billing provider's ZIP Code.

Bill Type

Enter the Medicare Bill Type listed on the Medicare Remittance Advice/Remittance Notice.

Note: The Medicare Bill Type may not match the TOB listed on the claim form.

From DOS

Enter the first date of service for all procedures in a MM/DD/YYYY format.

Through DOS

Enter the last date of service for all procedures in a MM/DD/YYYY format.

Patient Last Name

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

Patient First Name

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

Medicare HIC

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

Medicare ICN

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

Total Charges

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

Covered Charges

Enter the covered charges listed on the Medicare Remittance Advice/Remittance Notice.

Non Covered Charges/Reason Code

Enter the non covered charges listed on the Medicare Remittance Advice/Remittance Notice followed by the reason code listed on the Medicare Remittance Advice/Remittance Notice.

DRG Amount

Enter the DRG amount listed on the Medicare Remittance Advice/Remittance Notice for inpatient claims, if applicable.

Note: Outpatient claims do not require a DRG amount.

Deductible

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

Blood Deductible

Enter the blood deductible listed on the Medicare Remittance Advice/Remittance Notice for inpatient claims, if applicable.

Note: Outpatient claims do not require a blood deductible amount.

Coinsurance

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

Medicare Paid Amount

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

DRG Code

Enter the DRG code listed on the Medicare Remittance Advice/Remittance Notice for inpatient claims, if applicable.

Note: Outpatient claims do not require a DRG code.


Texas Medicaid & Healthcare Partnership
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