When the same payer issues the primary secondary or supplemental policies the correct procedure for submitting the claim would be?

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This list reflects answers to frequently asked questions regarding Secondary Claims (a.k.a. Crossovers).

• There are two ways Medicare secondary claims are sent or “crossed over” to Medicaid. Either they are sent to Medicaid directly from a Medicare carrier, such as with most professional and inpatient claims, or they are sent to Medicaid from the provider through the NCTracks provider portal, a billing agent or trading partner/clearinghouse, such as with outpatient claims.

• 1. 1. Missing Billing or Rendering Provider Taxonomy Codes
     2. Billing NPI submitted with Rendering Provider Taxonomy Code (or vice versa)
     3. Invalid Taxonomy Code submitted with Billing or Rendering NPI

  All secondary claims should be billed with the appropriate Billing AND Rendering Provider Taxonomy Codes from the NCTracks provider record.

• No. These claims are sent to Medicaid either through the providers billing agent or trading partner/clearinghouse or the NCTracks provider portal. 

• These claims should be resubmitted to Medicaid either through the provider’s billing agent or trading partner/clearinghouse or the NCTracks provider portal.

• All information submitted to the primary payer should be retained and passed on to Medicaid, even though it might be information the primary payer does not require. Providers should contact their Medicare carrier or their billing agent or trading partner/clearinghouse if they suspect that data is not being passed to Medicaid.

• Yes. If your claim is submitted to Medicaid either as a crossover or as a secondary claim, without taxonomy codes, it will be denied. The claim can be resubmitted with correct billing and rendering taxonomy codes.

• Taxonomy codes provide a standard provider classification system and are a fundamental construct used throughout the Medicaid claims billing system, NCTracks taxonomy codes are connected to provider records, benefit plans, procedure codes, fee schedules, and claim adjudication rules.

• The Provider Taxonomy Lookup page has been retired.  Providers should use the Status & Management page in the secure NCTracks Provider Portal to verify the taxonomy code(s) associate with their NPI.

• No. Medicaid is the payer of last resort and providers who accept Medicaid patients agree to take assignment from Medicaid.  Providers cannot charge the patient for the balance of what is not paid by Medicaid.

• Secondary claims can be submitted or resubmitted to NCTracks either as an X12 transaction or through the Provider Portal with the assistance of a billing agent/ clearinghouse or directly. If you wish to bill X12 transactions directly to NCTracks, without use of a clearinghouse, you will need to set up a TPA and complete the testing and certification process.

• Medicaid will process Medicare secondary claims even if they include procedure codes that Medicaid doesn’t cover; however, all services billed to Medicaid are subject to Medicaid policy and may be denied by Medicaid even if they are covered by Medicare.

• The time frame for claim submission is 6 months/180 days for all secondary claims and 365 days for Medicaid primary claims. For more information, please see the How to Submit Claim Adjustments and Time Limit and Medicare Override Job Aid under the heading Claims Submission on the User Guides & Fact Sheets page.

• Loop 2320 contains the Other Subscriber Information. Please refer to the HIPAA 837 Companion Guides on the Trading Partner Information page of the NCTracks Provider Portal for more details.

• If the billed services are covered by Medicaid and the claim meets all the criteria for reimbursement then the status of the claim is paid, even if the Medicaid allowable amount is calculated as $0.

• These $0 paid claims will be found in the paid section of the Medicaid EOB/RA.

• This is a known issue with durable medical equipment claims. NCTracks edits all fields on a claim, including claims crossed over from Medicare. It is necessary to make these secondary claims “NC Medicaid ready”.

  To make a claim “NC Medicaid ready”:

  • Include a third level NC Medicaid Taxonomy
  • Add the appropriate NC Medicaid modifier in the first modifier position
  • Indicate the span of from and to dates the rental item was used for the month being billed– (NC Medicaid pays a prorated monthly amount based on the number of days the equipment was used during the PA period)
  • Avoid spanning across months within the date range on a given line item (e.g.: 2/20/19-3/19/19 should be billed on two separate lines - one line for February and one line for March)
  • Enter units equal to one for each rental month per line

• Please contact the NCTracks Call Center (1-800-688-6696) with any questions regarding billing or processing of secondary crossover claims.

• It is not typically required for payment but there may be some circumstances where an EOB is needed. For more information, please see the How to Indicate Other Payer Details Job Aid under the heading Claims Submission on the User Guides & Fact Sheets page.

• If you are submitting the original claim to NCTracks with secondary information, document only the recoupment details for the primary payer. If you previously submitted the original claim indicating a payment by the primary payer, submit a replacement claim and indicate the recoupment details.

• Go to the Provider Communication page on the NCTracks Provider Portal.  On the upper right side of the page under the header "Sign up for NCTracks Communications", click “Click here to join Mailing list”. You will be asked to provide your email address, which will add you to the listserv to receive future provider communications, including the weekly newsletter.

For Medicare programs to work effectively, providers have a significant responsibility for the collection and maintenance of patient information. They must ask questions to secure employment and insurance information. They have a responsibility to identify payers other than Medicare so that incorrect billing and overpayments are minimized. Providers must determine if Medicare is the primary or secondary payer; therefore, the beneficiary must be queried about other possible coverage that may be primary to Medicare. Failure to maintain a system of identifying other payers is viewed as a violation of the provider agreement with Medicare.

Responsibilities of Providers Under MSP

As a Part A institutional provider (i.e. hospitals), you should:

• Obtain billing information prior to providing hospital services. It is recommended that you use the CMS Questionnaire (available in the Downloads section below), or a questionnaire that asks similar types of questions; and
• Submit any MSP information to the intermediary using condition and occurrence codes on the claim.

As a Part B provider (i.e. physicians and suppliers), you should:

• Obtain billing information at the time the service is rendered.  It is recommended that you use the CMS Questionnaire (available in the Downloads section below), or a questionnaire that asks similar types of questions; and
• Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier.  If submitting an electronic claim, provide the necessary fields, loops and segments needed to process an MSP claim.

The CMS Questionnaire should be used to determine the primary payer of the beneficiary’s claims. This questionnaire consists of six parts and lists questions to ask Medicare beneficiaries. For institutional providers, ask these questions during each inpatient or outpatient admission, with the exception of policies regarding Hospital Reference Lab Services, Recurring Outpatient Services, and Medicare+Choice Organization members. (Further information regarding these policies can be found in Chapter 3 of the MSP Online Manual.) Use this questionnaire as a guide to help identify other payers that may be primary to Medicare. Beginning with Part 1, ask the patient each question in sequence. Comply with all instructions that follow an answer. If the instructions direct you to go to another part, have the patient answer, in sequence, each question under the new part. Note: There may be situations where more than one insurer is primary to Medicare (e.g., Black Lung Program and Group Health Plan). Be sure to identify all possible insurers.

Note: There are programs under which payment for services is usually excluded from both primary and secondary Medicare benefits.

• Veteran’s Administration (VA) Benefits - Medicare does not pay for the same services covered by VA benefits. For further information about VA benefits, contact the VA Administration at 1-800-827-1000.
• Federal Black Lung Benefits - Medicare does not pay for services covered under the Federal Black Lung Program. However, if a Medicare-eligible patient has an illness or injury not related to black lung, the patient may submit a claim to Medicare. For further information, contact the Federal Black Lung Program at 1-800-638-7072.

Medicare is the Secondary Payer when Beneficiaries are:

• Treated for a work-related injury or illness. Medicare may pay conditionally for services received for a work-related illness or injury in cases where payment from the state workers’ compensation (WC) insurance is not expected within 120 days. This conditional payment is subject to recovery by Medicare after a WC settlement has been reached. If WC denies a claim or a portion of a claim, the claim can be filed with Medicare for consideration of payment.
• Treated for an illness or injury caused by an accident, and liability and/or no-fault insurance will cover the medical expenses as the primary payer.
• Covered under their own employer’s or a spouse’s employer’s group health plan (GHP).
• Disabled with coverage under a large group health plan (LGHP).
• Afflicted with permanent kidney failure (End-Stage Renal Disease) and are within the 30-month coordination period. See ESRD link in the Related Links section below for more information. Note: For more information on when Medicare is the Secondary Payer, click the Medicare Secondary Payer link in the Related Links section below.

MSP Retirement Date Policy

CMS developed an operational policy to help alleviate a major concern that hospitals have had regarding completion of the CMS Questionnaire.

During the intake process, what should be reported when a beneficiary cannot recall his/her precise retirement date or that of his/her spouse if formerly covered as a dependent under the spouse's group health plan (GHP)?

When a beneficiary cannot recall his/her retirement date, but knows it occurred prior to his/her Medicare entitlement dates, as shown on his/her Medicare card, hospitals report his/her Medicare Part A entitlement date as the date of retirement. If the beneficiary is a dependent under his/her spouse's group health insurance and the spouse retired prior to the beneficiary's Medicare Part A entitlement date, hospitals report the beneficiary's Medicare entitlement date as his/her retirement date. If the beneficiary worked beyond his/her Medicare Part A entitlement date, had coverage under a group health plan during that time, and cannot recall his/her precise date of retirement but the hospital determines it has been at least five years since the beneficiary retired, the hospital enters the retirement date as five years retrospective to the date of admission. (Example: Hospitals report the retirement date as January 4, 1998, if the date of admission is January 4, 2003)

As applicable, the same procedure holds for a spouse who had retired at least five years prior to the date of the beneficiary's hospital admission. If a beneficiary's (or spouse's, as applicable) retirement date occurred less than five years ago, the hospital must obtain the retirement date from appropriate informational sources; e.g., former employer or supplemental insurer.