How Crossover Claims Are Processed for Beneficiaries in MLTSS
DRAFT – 7/15/14
How Crossover Claims are Processed for Beneficiaries in MLTSS
Under the Coordinated Care Initiative (CCI), certain beneficiaries who choose not to enroll in Cal MediConnect will still be mandatorily enrolled in Medi-Cal plans for long-term supports and services (MLTSS). This document explains how to seek the Medi-Cal payment portion for MLTSS beneficiaries in Medicare Fee-For-Service.
For such beneficiaries Medicare should be billed and will pay 80% of the Medicare fee schedule. The 20% copay cannot be billed to dual eligible patients. Instead, these “crossover claims” must go to the patient’s Medi-Cal plan, which will pay any amount owed.
The CMS Coordination of Benefits Agreement (COBA)Programallows these crossover claims to go directly to the Medi-Cal plan through a Coordination of Benefits Contractor (COBC) after the claims have been submitted to Medicare. As not all Medi-Cal plans are yet participating in this automated process, the chart below outlines how Medicare providers should submit their Medi-Cal claims to each plan.
Please note that since 1982, state law has limited Medi-Cal’s reimbursement on Medicare claims to an amount that, when combined with the Medicare payment, does not exceed Medi-Cal’s maximum payment for similar services. Consequently, if the Medi-Cal rate is 80% or less than the Medicare rate for the service rendered, Medi-Cal will not reimburse anything on these crossover claims.
Physicians do not need to be in a plan’s network to submit a crossover claim.
Health plan / CCI County participation / If a provider needs to submit a Medi-Cal crossover claim, how should they do that?Alameda Alliance / Alameda / Providers need to submit crossover claims on paper with Medicare’s EOB attached. Send to:
Alameda Alliance Claims Dept
PO Box 2460
Alameda, CA 94501
Anthem/ Wellpoint / Alameda and Santa Clara / Providers would submit a Medi-Cal claim via paper with a copy of the EOP from the other carrier.
Anthem Blue Cross
P.O. Box 60007
Los Angeles, Ca. 90060-0007
Crossover Claims Procedures:In most cases, when a resident has met the criteria for a Medicare-qualified stay in a certified Medicare bed, the Medicare cost share will be relayed to Anthem via a crossover file provided to Anthem. We will then process and adjudicate the crossover claim. No further action should be necessary by the provider. Should Anthem not receive a crossover claim, then a claim can be submitted by the provider with a copy of the EOP from the other carrier for processing.
CalOptima / Orange / Cal Optima receives CrossOver claims for Part A and Part B electronically through DHCS proprietary files. Providers should submit all other claims as paper claims:
CalOptima CMC Crossover Claim
P.O. Box 11070
Orange, CA 92856
Health plan / CCI County participation / If a provider needs to submit a Medi-Cal crossover claim, how should they do that?
Care1st / San Diego and Los Angeles / Medicare EOB must be submitted with the claim.
Paper claims can be mailed to:
Care1st Health Plan
Mail Stop: CL005 (COB)
601 Potrero Grande Drive
Monterey Park, CA 91755
CareMore (Anthem ) / Los Angeles / Providers should submit a Medi-Cal claim via paper with a copy of the EOP from the other carrier.
CareMore Health Plan
Attn: Claims Dept – Duals
MS-6110
P.O. Box 366
Artesia, CA 90702
Phone:1-877-211-6553
Fax:1-562-741-4403
Crossover Claims Procedures:In most cases, when a resident has met the criteria for a Medicare qualified stay in a certified Medicare bed, the Medicare cost share will be relayed to CareMore via a crossover file provided to CareMore. We will then process and adjudicate the crossover claim. No further action should be necessary by the provider.
Community Health Group / San Diego / Providers should send to:
Community Health Group
Claims Payment
2420 Fenton street
Suite 100
Chula Vista CA 91914
HealthNet / San Diego and Los Angeles / Providers would need to submit their claims with the Medicare EOB via paper to the following addresses:
Health Net Medi-Cal Claims
P.O. Box 14598
Lexington, KY 40512
Health Net Medicare Claims
P.O. Box 14703
Lexington, KY 40512
If a crossover claim is submitted where the member has Health Net coverage for Medicare and for Medi-Cal, the claim is routed internally for processing. If the member has another Plan for their Medicare the provider would bill them first. Then if that claim needs to come to Health Net to be paid under the Medi-Cal benefit it would be as a paper claim.
Health plan / CCI County participation / If a provider needs to submit a Medi-Cal crossover claim, how should they do that?
Health Plan of San Mateo / San Mateo / Providers should submit on paper with the payment information (EOB) of the primary payer. Crossover claims billed with a copy of the EPMB from Medicare to:
HPSM
701 Gateway Blvd., Ste 400
South San Francisco, CA 94080
LA Care / Los Angeles / Providers should submit paper claims and EOMBs. Once the implementation is complete no paper claim is required.
Providers can mail the paper claim and the EOMB to:
L.A. Care Claims Department
P.O. Box 811580
Los Angeles, CA 90081
Molina / Riverside, San Bernardino, and Los Angeles / Molina currently accepts both paper and electronic claims.
Providers should send paper claims to:
P.O. Box 22702
Long Beach, CA 90801
Send EDI to:
P.O. Box 22807
Long Beach, CA 90801
Electronic EDI Submission:
EDI Vendor: EMDEON
Emdeon Payer ID: 38333
Santa Clara Family Health Plan / Santa Clara / Providers must attach the EOB or RA of the primary insurance to allow SCFHP to coordinate benefits under Medi-Cal. Providers can mail paper claims (UB-04 and CMS 1500) to:
SCFHP, P.O. Box 5550
San Jose, CA 95150-5550.
Providers can electronically submit their claims as HIPAA compliant X12 837 5010 P/I transactions to our clearinghouse—Office Ally. Providers must attach the EOB or RA of the primary insurance to allow SCFHP to coordinate benefits under Medi-Cal.