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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.12 Filing Medicare Primary Claims : 6.12.2 Paper Crossovers Claims

6.12.2
TMHP accepts only paper crossover claims or appeals from providers and other entities.
The following paper crossover claims may be submitted to TMHP:
For QMB and MQMB clients, if a crossover claim is not transferred to TMHP electronically through the COBC, the provider can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration.
For MQMB clients, if a claim is denied by Medicare because the services are not a benefit of Medicare or because Medicare benefits have been exhausted, the provider can submit a paper claim to TMHP for coinsurance and deductible reimbursement consideration, and reimbursement consideration for the Medicaid-only services that were denied by Medicare. The Medicare EOB that contains the relevant claim denial must be submitted to TMHP with the completed claim from within 95 days from the Medicare disposition date and 365 days from the date of service. The denied services are processed as Medicaid-only services.
Claims that are submitted to Medicare must include the facility’s NPI. Medicare crossover claims must comply with the Medicaid requirement to include a facility NPI. If a Medicare crossover claim includes a service for which Medicaid requires a facility NPI but the claim does not include the facility’s NPI number, the claim will be denied by Texas Medicaid.
Important:
The paper submission must include all of the following:
The Medicare Remittance Advice (RA) or Remittance Notice (RN), using the CMS-approved software MREP, for professional services, or PC-Print or a paper MRAN from Medicare.
The appropriate TMHP Standardized Medicare Advantage Plan (MAP) Remittance Advice Notice Template for Medicare Advantage Plan only. The template must be submitted with the claims form and the MAP EOB.
Providers that receive Remittance Advice Notices from a Medicare intermediary may submit these in place of the MRAN to TMHP which must contain the following required information:

Texas Medicaid & Healthcare Partnership
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