Medicare Part B 101 Manual

Medigap

Table of Contents

• Medigap
• Medigap Crossover Billing Procedures
• Item 13 Completion Requirement
• Automatic Crossover
• Medigap Versus Commercial Crossovers
• Medicaid Crossovers

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Medigap

The OBRA of 1987 provided an incentive for physicians/suppliers to become participating with the Medicare Program by providing a system for speeding payment of Medicare supplemental insurance benefits to participating physicians/suppliers. This system is referred to as Medigap.

The Medigap provision applies only to Medicare supplemental policies the Medicare patient pays for out of his/her own pocket and is not a policy they are paying for as a result of his/her present or former employment or the spouse’s present or former employment. Supplemental policies available as a result of employment are considered “Employer Supplement” policies and do not qualify under the Medigap provision.

As a general rule, a beneficiary purchases a Medigap policy to pick up and pay the Medicare deductibles and coinsurance amounts. Medigap policies may also provide coverage for services not covered by Medicare.

The Medigap provision requires Medicare carriers to send Medicare payment information directly to eligible Medigap insurers who, in turn, are required to accept this information as a claim for payment and make the supplemental payment directly to the Medicare participating physician/supplier. Carriers are only required to forward payment information to one Medigap insurer regardless of how many such policies a beneficiary may have.

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Medigap Crossover Billing Procedures

For the Medigap provision to “crossover” to the supplemental insurer, the following steps must be taken in Items 9–9d of the CMS-1500 claim form.

Also, for the carrier to forward claim information to the Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in Items 9, 9a and 9d. A Medicare participating provider or supplier shall only enter the COBA Medigap claim based ID within item 9d when seeking to have a beneficiary’s claims crossed over to a Medigap insurer.

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Item 13 Completion Requirement

The signature in this item authorizes payment of mandated Medigap benefits to the participating physician or supplier if required Medigap information is included in Item 9 and its subdivisions. The patient or his/her authorized representative signs this item or the signature must be on file as a separate Medigap authorization. The Medigap assignment on file in the participating provider of service/supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

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Automatic Crossover

Medicare carriers forward payment/denial information to Medigap insurers, supplemental insurers and state Medicaid offices on assigned claims only. The information provided by Medicare is very similar to the information that appears on the provider remittances. It is the secondary insurer’s responsibility, however, to crosswalk this information to their own format.

The secondary insurer may choose to receive all claims, only allowed claims or only claims allowed at less than 100 percent; however, the crossover of information occurs only once. Medicare cannot recreate a crossover claim. If the crossover information was not received or adapted to the secondary insurer’s format, the provider will have to file a claim with that insurer and include a copy of the Medicare remittance or a copy of the beneficiary’s MSN.

The supplemental insurance companies provide the carrier with the name and identification number of their policyholder that is then cross-referenced to the policyholder’s MBI. This allows the electronic transfer of the Medicare claim disposition to them without the provider having to provide this information on their claim to Medicare.

Note: It is the supplemental insurer’s responsibility to notify the carrier of their policyholder changes, additions and deletions.

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Medigap Versus Commercial Crossovers

While the Medigap provision may be viewed as a “crossover” supplemental policy, there are differences between it and other commercial supplemental policies.

Medigap is a federal provision enacted as an incentive for physicians and suppliers to become participating with the Medicare Program. The incentive is that if the claim is completed accurately and the beneficiary wishes the Medicare participating provider to receive his/her supplemental benefits, the following applies:

The carrier must forward payment information directly to that Medigap insurer.

• In other commercial insurance policy crossovers, carriers forward payment/denial information only if requested by the individual insurance company and only if the insurer pays an administrative fee to receive it.
• The Medigap insurer must accept the information as a claim and make payment to the Medicare participating provider without regard to its own provider versus policyholder payment policy.
• In other commercial insurance policy crossovers, the insurer has the option of paying their supplemental benefits to the provider of service or its policyholder.

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Medicaid Crossovers

Medicaid is the government program that insures lower income individuals. Medicaid is a totally separate program from Medicare and is run by individual states.

If a patient is dually entitled to Medicare and Medicaid, providers must submit assigned claims and provide the patient’s Medicaid number in Item 10d of the claim. The actual crossover, however, is triggered directly by an eligibility tape that Medicaid must furnish to Medicare.

Note: Medicare is primary to Medicaid.

Medicare will forward claim information to Medicaid if the most recent Medicaid eligibility tape indicates that the beneficiary is dually entitled. Eligibility file information is updated each time an eligibility tape is received to ensure that Medicare’s files remain current. When Medicare to Medicaid crossover data is not received at the Medicaid office, incorrect or incomplete eligibility tape information is most often at fault. As in any crossover situation where the secondary payer does not receive the Medicare crossover information, the provider will have to file a claim and attach a copy of the Medicare remittance or a copy of the patient’s MSN.

Reviewed 10/15/2024