Important Information Regarding the Centers for Medicare & Medicaid Services (CMS) National Claims Crossover Process

This special edition article is to request that Physicians, providers, allow sufficient time for the Medicare crossover process before attempting to balance bill their patients’ supplemental insurers and payers for amounts remaining after Medicare’s payment determination on their submitted claims.

• CMS consolidated the “automatic” or eligibility file-based crossover process under the Coordination of Benefits Contractor (COBC) as of September 2006. Under the “automatic” crossover process, other supplemental insurers, including Medicaid agencies, sign a standard national Coordination of Benefits Agreement (COBA) with the CMS contractor, the COBC. They then submit enrollment information via a standard eligibility file feed through a secure connection with the COBC. Within this eligibility feed, the supplemental insurers identify their covered members or policy/ certificate holders for Medicare claim matching purposes. The COBC, in turn, transmits this information to the CMS Common Working File (CWF). After the CMS CWF system tags individual claims for crossover to a designated insurer, it then prompts the Medicare contractor to send the adjudicated claims to the COBC for crossover purposes once the claims have met their payment floor requirements, as prescribed by CMS.
• CMS consolidated the Medigap claim-based crossover process under the COBC in October 2007. Under this process, the COBC assigns to a Medigap plan a 5-digit or 837 professional claims, the Medicare contractor will be able to transfer the claims to the COBC for crossover to that specific Medigap plan. Virtually all Medigap insurers participate in the automatic or eligibility file-based crossover process

Since payment from supplemental insurers should, as a rule, occur only after the Medicare payment has been issued, CMS requests that you do not bill your patients’ supplemental insurers for a minimum of 15 work days after receiving the Medicare payment.