Medicare/Medi-Cal Crossover Claims: medi cr op ex
Outpatient Services Billing Examples 1
This section illustrates billing examples of Medicare/Medi-Cal crossover claims for outpatient services on the CMS-1500 or UB-04 claim and correlating Medicare Remittance Advice (RA) examples. Billing examples for Rural Health Clinics (RHCs)/Federally Qualified Health Centers (FQHCs), Part B dialysis and split billing also appear in this section.
Refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in this manual for detailed billing and policy information. Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete claim fields not explained in the following examples. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual.
The examples in this section do not necessarily represent current Medicare or Medi-Cal policy.
Note:A crossover claim reflects what was billed to Medicare, but only Medi-Cal-required fields are used for claims processing.
Billing Tips:When completing claims, do not enter the decimal points in ICD-10-CM codes or dollar
amounts. If requested information does not fit neatly in the Remarks field (Box 80) of the claim, type it on an 8½ x 11-inch sheet of paper and attach it to the claim.
Hard Copy Billing ExamplesThe following examples show how to bill hard copy Medicare/Medi-Cal crossover claims:
- Figures 1a and 1b. Billing Medi-Cal for Part B Services Billed to a Part B Contractor.
- Figures 2a and 2b. Outpatient Hospital Provider Billing
Medi-Cal for Part B Services Billed to a Part A Contractor With Coinsurance and Deductible. - Figure 3. Billing Medi-Cal forRural Health Clinics and Federally Qualified Health Centers.
- Figures 4a and 4b. Billing Medi-Cal for Part B Dialysis Services.
- Figures 5a, 5b, 5c and 5d. Billing for More Than 15 Line Items for Part B Services Billed to a Part A Contractor With Coinsurance.
- Figures 6a, 6b, 6c and 6d. Billing Medi-Cal for Part B Dialysis Services for More Than 15 Lines.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 521
Outpatient Services Billing ExamplesFebruary 2018
Medicare/Medi-Cal Crossover Claims: medi cr op ex
Outpatient Services Billing Examples 1
Figure 1a. Billing Medi-Cal for Part B Services Billed to a Part B Contractor.
2 – Medi/Medi Crossover Claims: Outpatient Services Billing ExamplesOutpatient Services
____2000
medi cr op ex
1
JANE SMITH05/30/18
1420 SECOND STREET
ANYTOWN, CA 95823-5555
Medicare Remittance NoticeMedicare Contractor (12345)
BENEFICIARY NAME / SERVICE / PLACE / PROCEDURE / AMOUNT / AMOUNT / SEE / DEDUCTIBLE / COINSURANCE / PAYMENT / INTEREST
MEDICARE ID/EX NO.
CONTROL NUMBER / FROM
MO-DAY / TO
DAY-YR / TYPE / CODE-MODIFIER / BILLED / ALLOWED / NOTE
JOHN DOE
9ZZ9ZZ9ZZ99
90000000A95001
CLAIM TOTALS / 05 01 18
05 01 18
05 01 18 / 05 01 18
05 01 18
05 01 18 / 22
22
22 / 99214
71020
93000 / 55.00
60.00
50.00
165.00 / 40.00
50.00
45.00
135.00 / 0.00
0.00
0.00
0.00 / 8.00
10.00
9.00
27.00 / 32.00
40.00
36.00
108.00 / 0.00
Figure 1b. Simplified Medicare Remittance Notice Example.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 522
Outpatient Services Billing ExamplesMarch 2018
medi cr op ex
1
Figure 2a. Hospital Outpatient Provider Billing Medi-Cal for Part B Services
Billed to a Part A Contractor.
2 – Medi/Medi Crossover Claims: Outpatient Services Billing ExamplesOutpatient Services
____2000
medi cr op ex
1
======
Medicare National Standard Intermediary Remittance Advice
Uptown Medical CenterFPE:02/01/16Medicare Contractor
140 Second StreetPAID:11/15/151234 B Street
Anytown, CA 95823-5555CLM#:166Anytown, CA 98765-5555
0123456789TOB:131555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2015MRN: 000193638
PAT STAT: CLAIM STAT: 19THRU: 10/01/2015ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG0.370=REIM RATE
3329.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS2871.64=LINE ADJ AMT0.00=ESRD AMOUNT
3329.00=COVERED0.00=OUTLIER (C)104.03=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER230.17=ALLOW/REIM
0=COST REPT100.0=CASH DEDUCT0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT0.00=INTEREST
0=NON-COVERED127.19=COINSURANCE0.00=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND0.37=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET230.17=NET REIM AMT
REMARK CODES:MA01
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
030010/0136415124.103.00CO4221.10
030110/01800531185.7514.77CO42170.98
030110/01838801216.0047.43CO42168.57
030110/01844841102.1013.75CO4288.35
030510/0185025180.5510.86CO4269.69
030510/01853791105.5014.22CO4291.28
032410/0171020002601183.0025.07CO45137.42
PR220.51
045010/0199283006112511315.004.07CO451173.36
PR1100.00
PR237.57
073010/0193005000991130.0018.05CO45107.44
PR24.51
092110/0193970002671987.0078.95CO45843.45
PR264.60
======
Figure 2b. Medicare Remittance Advice Example.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 522
Outpatient Services Billing ExamplesMarch 2018
Medicare/Medi-Cal Crossover Claims: medi cr op ex
Outpatient Services Billing Examples
Figure 3. Billing Medi-Cal for Rural Health Clinics/Federally Qualified Health Centers.
2 – Medi/Medi Crossover Claims: Outpatient Services Billing ExamplesOutpatient Services
____2000
medi cr op ex
1
Figure 4a. Billing Medi-Cal for Part B Dialysis Services.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 492
Outpatient Services Billing ExamplesSeptember 2015
medi cr op ex
9
======
Medicare National Standard Intermediary Remittance Advice
Uptown Medical CenterFPE:10/30/16Medicare Contractor
140 Second StreetPAID:11/15/161234 B Street
Anytown, CA 95823-5555CLM#:166Anytown, CA 98765-5555
0123456789TOB:721555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638
PAT STAT: CLAIM STAT: 1THRU: 10/24/2016ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG1.000=REIM RATE
4875.84=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS2.15=LINE ADJ AMT0.00=ESRD AMOUNT
4873.69=COVERED0.00=OUTLIER (C)334.09=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER3892.45=ALLOW/REIM
0=COST REPT0.0=CASH DEDUCT0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT0.00=INTEREST
0=NON-COVERED974.74=COINSURANCE0.00=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND0.00=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET3892.45=NET REIM AMT
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
027010/01A46572110.508.40PR22.10
063610/03J158043.803.04PR20.76
063610/10J291640198.00158.40PR239.60
063610/12907401113.9191.13PR222.78
077110/22G001017.886.30PR21.58
082110/2490999G4131496.631189.08CO976.50
452.15
PR275.47
======
Figure 4b. MedicareRemittance Advice Example.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 372
Outpatient Services Billing ExamplesOctober 2005
medi cr op ex
1
Figure 5a. Billing for More Than 15 Line Items for Part B Services Billed to Part A Contractors.
Split Bill Claim 1 of 2 (see also Figure 5c).
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 492
Outpatient Services Billing ExamplesSeptember 2015
medi cr op ex
10
Figure 5b(continued from 5a). Billing for More Than 15 Line Items for Part B Services
Billed to Part A Contractors. Split Bill Claim 2 of 2 (see also Figure 5d).
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 376
Outpatient Services Billing ExamplesFebruary 2006
medi cr op ex
1
======
Medicare National Standard Intermediary Remittance Advice
Uptown Medical CenterFPE:10/30/16Medicare Contractor
140 Second StreetPAID:11/21/161234 B Street
Anytown, CA 95823-5555CLM#:23Anytown, CA 98765-5555
0123456789TOB:131555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638
PAT STAT: CLAIM STAT: 1THRU: 10/16/2016ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE
2509.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
133.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS0.00=LINE ADJ AMT0.00=ESRD AMOUNT
2374.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER422.18=ALLOW/REIM
0=COST REPT0.00=CASH DEDUCT0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT0.00=INTEREST
0=NON-COVERED105.59=COINSURANCE1765.23=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND0.00=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET422.18=NET REIM AMT
REMARK CODES:MA01
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
042010/01G0238GP1101.009.70CO4288.87
PR22.43
042010/02G0238GP1101.009.70CO4288.87
PR22.43
042010/03G0238GP1101.009.70CO4288.87
PR22.43
042010/08G0238GP1101.009.70CO4288.87
PR22.43
042010/09G0238GP1101.009.70CO4288.87
PR22.43
042010/11G0238GP1101.009.70CO4288.87
PR22.43
042010/16G0238GP1101.009.70CO4288.87
PR22.43
042010/0197018GP166.500.00COB1566.50
042010/0297018GP166.500.00COB1566.50
042010/0197018GP183.0010.65CO4269.69
PR22.66
042010/0397110GP1109.0024.86CO4277.92
PR26.22
042010/0897110GP1109.0024.86CO4277.92
PR26.22
042010/0997110GP1109.0024.86CO4277.92
PR26.22
042010/1197110GP1109.0024.86CO4277.92
PR26.22
042010/1697110GP2218.0049.73CO42155.84
PR212.43
042010/0397140GP2191.5045.95CO42134.06
PR211.49
042010/0897140GP2191.5045.95CO42134.06
PR211.49
042010/0997140GP2191.5045.95CO42134.06
PR211.49
042010/1197140GP1109.0022.98CO4280.28
PR25.74
042010/1697140GP182.5022.98CO4252.78
PR25.74
======
Figure 5c. Medicare Remittance Advice Example Split Bill Claim 1 of 2.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 522
Outpatient Services Billing ExamplesMarch 2018
medi cr op ex
1
======
Medicare National Standard Intermediary Remittance Advice
Uptown Medical CenterFPE:10/30/16Medicare Contractor
140 Second StreetPAID:11/21/161234 B Street
Anytown, CA 95823-5555CLM#:23Anytown, CA 98765-5555
00454TOB:131555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2016MRN: 000193638
PAT STAT: CLAIM STAT: 1THRU: 10/16/2016ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE
2509.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
133.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS0.00=LINE ADJ AMT0.00=ESRD AMOUNT
2374.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER422.18=ALLOW/REIM
0=COST REPT0.00=CASH DEDUCT0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT0.00=INTEREST
0=NON-COVERED105.59=COINSURANCE1765.23=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND0.00=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET422.18=NET REIM AMT
REMARK CODES:MA01
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
042010/01G0238GP1101.009.70CO4288.87
PR22.43
042010/02G0238GP1101.009.70CO4288.87
PR22.43
042010/03G0238GP1101.009.70CO4288.87
PR22.43
042010/08G0238GP1101.009.70CO4288.87
PR22.43
042010/09G0238GP1101.009.70CO4288.87
PR22.43
042010/11G0238GP1101.009.70CO4288.87
PR22.43
042010/16G0238GP1101.009.70CO4288.87
PR22.43
042010/0197018GP166.500.00COB1566.50
042010/0297018GP166.500.00COB1566.50
042010/0197018GP183.0010.65CO4269.69
PR22.66
042010/0397110GP1109.0024.86CO4277.92
PR26.22
042010/0897110GP1109.0024.86CO4277.92
PR26.22
042010/0997110GP1109.0024.86CO4277.92
PR26.22
042010/1197110GP1109.0024.86CO4277.92
PR26.22
042010/1697110GP2218.0049.73CO42155.84
PR212.43
042010/0397140GP2191.5045.95CO42134.06
PR211.49
042010/0897140GP2191.5045.95CO42134.06
PR211.49
042010/0997140GP2191.5045.95CO42134.06
PR211.49
042010/1197140GP1109.0022.98CO4280.28
PR25.74
042010/1697140GP182.5022.98CO4253.78
PR25.74
======
Figure 5d. Medicare Remittance Advice Example Split Bill Claim 2 of 2.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 376
Outpatient Services Billing ExamplesFebruary 2006
medi cr op ex
1
Figure 6a. Billing Medi-Cal for Part B Dialysis Services for More Than 15 Lines.
Split Bill Claim 1 of 2 (see also Figure 6c).
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 492
Outpatient Services Billing ExamplesSeptember 2015
medi cr op ex
10
Figure 6b(continued from 6a). Billing Medi-Cal for Part B Dialysis Services for More Than 15 Lines.
Split Bill Claim 2 of 2 (see also Figure 6d).
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 376
Outpatient Services Billing ExamplesFebruary 2006
medi cr op ex
1
======
Medicare National Standard Intermediary Remittance Advice
A1 DialysisFPE:10/30/15Medicare Contractor
100 First StreetPAID:11/15/155555 55th Street
Anytown, CA 95823-5555CLM#:166City, CA 90000-9000
0123456789TOB:721555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2015MRN: 000193638
PAT STAT: CLAIM STAT: 1THRU: 10/30/2015ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE
4875.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS0.00=LINE ADJ AMT 0.00=ESRD AMOUNT
4875.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER3900.67=ALLOW/REIM
0=COST REPT0.00=CASH DEDUCT 0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST
0=NON-COVERED975.23=COINSURANCE0.00=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET3900.67=NET REIM AMT
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
027010/01A46572110.508.40PR22.10
063510/01Q4081133045.122436.10PR2609.02
063610/05J15801.95.76PR20.19
063610/12J15801.95.76PR20.19
063610/19J15801.95.76PR20.19
063610/26J15801.95.76PR20.19
063610/05J29161049.5039.60PR29.90
063610/12J29161049.5039.60PR29.90
063610/19J29161049.5039.60PR29.90
063610/26J29161049.5039.60PR29.90
063610/01907401113.9191.13PR222.78
077110/01G001017.886.30PR21.58
082110/0190999G41115.1392.10PR223.03
082110/05909991115.1392.10PR223.03
082110/07909991115.1392.10PR223.03
082110/09909991115.1392.10PR223.03
082110/12909991115.1392.10PR223.03
082110/14909991115.1392.10PR223.03
082110/16909991115.1392.10PR223.03
082110/19909991115.1392.10PR223.03
082110/21909991115.1392.10PR223.03
082110/23909991115.1392.10PR223.03
082110/26909991115.1392.10PR223.03
082110/28909991115.1392.10PR223.03
082110/30909991115.1392.10PR223.03
======
Figure 6c. Medicare Remittance Advice Example. Split Bill Claim 1 of 2.
Note: Supplies and Epoetin are not subject to Medicare’s line item billing requirement.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 522
Outpatient Services Billing ExamplesMarch 2018
medi cr op ex
1
======
Medicare National Standard Intermediary Remittance Advice
A1 DialysisFPE:10/30/15Medicare Contractor
100 First StreetPAID:11/15/155555 55th Street
Anytown, CA 95823-5555CLM#:166City, CA 90000-9000
0123456789TOB:721555-555-5555
======
PATIENT: DOE, JANEPCN: 123456789
MEDICARE ID: 9ZZ9ZZ9ZZ99SVC FROM: 10/01/2015MRN: 000193638
PAT STAT: CLAIM STAT: 1THRU: 10/30/2015ICN: 12345678901234
======
CHARGES:PAYMENT DATA: =DRG0.290=REIM RATE
4875.00=REPORTED0.00=DRG AMOUNT0.00=MSP PRIM PAYER
0.00=NCVD/DENIED0.00=DRG/OPER/CAP0.00=PROF COMPONENT
0.00=CLAIM ADJS0.00=LINE ADJ AMT 0.00=ESRD AMOUNT
4875.00=COVERED0.00=OUTLIER (C)0.00=PROC CD AMOUNT
DAYS/VISITS:0.00=CAP OUTLIER3900.67=ALLOW/REIM
0=COST REPT0.00=CASH DEDUCT 0.00=G/R AMOUNT
0=COVD/UTIL0.00=BLOOD DEDUCT 0.00=INTEREST
0=NON-COVERED975.23=COINSURANCE0.00=CONTRACT ADJ
0=COVD VISITS0.00=PAT REFUND 0.00=PER DIEM AMT
0=NCOV VISITS0.00=MSP LIAB MET3900.67=NET REIM AMT
======
REVDATEHCPCSAPC/HIPPSMODSQTYCHARGESALLOW/REIMGCRSNAMOUNTREMARK CODES
027010/01A46572110.508.40PR22.10
063510/01Q4081133045.122436.10PR2609.02
063610/05J15801.95.76PR20.19
063610/12J15801.95.76PR20.19
063610/19J15801.95.76PR20.19
063610/26J15801.95.76PR20.19
063610/05J29161049.5039.60PR29.90
063610/12J29161049.5039.60PR29.90
063610/19J29161049.5039.60PR29.90
063610/26J29161049.5039.60PR29.90
063610/01907401113.9191.13PR222.78
077110/01G001017.886.30PR21.58
082110/0190999G41115.1392.10PR223.03
082110/05909991115.1392.10PR223.03
082110/07909991115.1392.10PR223.03
082110/09909991115.1392.10PR223.03
082110/12909991115.1392.10PR223.03
082110/14909991115.1392.10PR223.03
082110/16909991115.1392.10PR223.03
082110/19909991115.1392.10PR223.03
082110/21909991115.1392.10PR223.03
082110/23909991115.1392.10PR223.03
082110/26909991115.1392.10PR223.03
082110/28909991115.1392.10PR223.03
082110/30909991115.1392.10PR223.03
======
Figure 6d. Medicare Remittance Advice Example. Split Bill Claim 2 of 2.
Note: Supplies and Epoetin are not subject to Medicare’s line item billing requirement.
2 – Medicare/Medi-Cal Crossover Claims:Outpatient Services 376
Outpatient Services Billing ExamplesFebruary 2006