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Updates to Medicare Crossover Claim Co-Payments Effective December 6, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

The following Texas-specific Medicare co-pay procedure codes will be discontinued for dates of service on or after December 6, 2024:

  • CP003: Medicare HMO Co-pay — Professional
  • CP004: Medicare PPO Co-pay — Professional
  • CP007: Medicare HMO Co-pay — Outpatient
  • CP008: Medicare PPO Co-pay — Outpatient

Acute care providers must bill claims for Medicare co-payments for non-contracted Medicare Advantage Plan (MAP) clients on dual-eligible professional and outpatient facility claims as MAP Crossover claims. The procedure code billed on the crossover claim will now reflect the service that was rendered and billed to the MAP rather than the Texas-specific Medicare co-pay code. The MAP co-payment will be billed and considered a patient liability amount in the same manner as Medicare coinsurance.

Electronic Claims

Providers submitting electronic MAP Crossover claims must use the co-payment Claim Adjustment Reason Code (CARC) on the X12 837 transaction. Complete details for electronic claims will be available in the updated 837I and 837P Acute Care Companion Guides and the new 275 Acute Care Companion Guide.

The companion guides are available on tmhp.com as announced in a provider notification titled “Updated 837I and 837P Acute Care Companion Guides and New 275 Acute Care Companion Guide Now Available.”

Providers that want to submit electronic claims to the Texas Medicaid & Healthcare Partnership (TMHP) can refer to the “Get Started” section on TMHP’s Electronic Data Interchange (EDI) web page.

For questions about EDI testing or submission, call the TMHP EDI Help Desk at 888-863-3638.

Paper Claims

For providers filing MAP Crossover claims on paper, the amount indicated on the MAP Explanation of Benefits (EOB) will be included on the appropriate TMHP Standardized MAP Remittance Advice Notice template in the existing Coinsurance or Coins field.

For more information, call the TMHP Contact Center at 800-925-9126.