Trading Partner/Supplemental Insurer Criteria Selections - JF Part B

Medicare contractors coordinate with the Benefits Coordination & Recovery Center (BCRC), Group Health Incorporated (GHI), to automatically cross over claims payment information for their policyholders.

An eligibility file furnished by the supplemental insurer is used to drive the process rather than information found on the claim. These eligibility files are matched, based on the Medicare ID, against Medicare's internal eligibility file. If a match occurs, the beneficiary's record is flagged indicating to which company we will cross claim payment information. Noridian then sends the file of claims to the BCRC who consolidates the claims for all contractors and forwards it on to the trading partner/supplemental insurer. If no match occurs, the claim is not flagged for crossover.

Each trading partner/supplemental insurer is given the opportunity to specify criteria related to the claims the insurer wants or does not want Medicare to crossover.

Trading partner/supplemental insurer can choose from below conditions to allow or refuse a claim crossover from Medicare.

• Medicare Secondary Payer (MSP) Claims
• MSP Cost Avoid Claims
• Claims if other insurance (such as Medigap, supplemental, TRICARE, or other) exists for beneficiary. Applies to State Medicaid Agencies only.
• Claim is a mass adjustment- Medicare Physician Fee Schedule (MPFS)
• Claim is a mass adjustment-Other
• Claim is an archived adjustment
• A specific Contractor ID
• A specific provider identification (ID) or provider state
• Original Fully Paid Medicare claims without deductible and co-insurance remaining
• Original Medicare claims paid at greater than 100% of the submitted charges without deductible or co-insurance remaining (Part A) - Also covers the exclusion of Original Medicare claims paid at greater than 100% of submitted charges excluded for Part B ambulatory surgical center (ASC)
• Adjustments
• Adjustments, non-monetary/statistical claims
• Adjustments, monetary claims
• Adjustment claim that includes an original claim that was not crossed over
• 100% denied claims, with additional beneficiary liability
• 100% denied claims, with no additional beneficiary liability
• Adjustment claim, 100% denied, with additional beneficiary liability
• Adjustment claim, 100% denied, with no additional beneficiary liability
• Adjustment fully paid claims with no deductible or co-Insurance remaining
• Original claims paid at greater than 100% of submitted charge
• Original claims paid at 100%
• Fully reimbursable claim containing denied lines with no beneficiary liability
• Invalid Claim-based Medigap crossover ID included on the claim
• Non-assigned claims
• Claim contains a placeholder provider value
• Claim represents an excluded demonstration (DEMO) project
• National Council Prescription Drug Program Claims
• Type of Bill (TOB) 11 - Hospital: Inpatient Part A
• TOB 12 - Hospital: Inpatient Part B
• TOB 13 - Hospital: Outpatient
• TOB 14 - Hospital: Other Part B (Non-patient)
• TOB 18 - Hospital: Swing Bed
• TOB 21 - Skilled Nursing Facility: Inpatient Part A
• TOB 22 - Skilled Nursing Facility: Inpatient Part B
• TOB 23 - Skilled Nursing Facility: Outpatient
• TOB 24 - Skilled Nursing Facility: Other Part B (Non-patient)
• TOB 28 - Skilled Nursing Facility: Swing Bed
• TOB 32 - Home Health: Part B Trust Fund
• TOB 33 - Home Health: Part A Trust Fund
• TOB 34 - Home Health: Outpatient
• TOB 41 - Christian Science/Religious Non-Medical Services (Hospital)
• TOB 71 - Clinic: Rural Health
• TOB 72 - Clinic: Freestanding Dialysis
• TOB 73 - Clinic: Federally Qualified Health Center
• TOB 74 - Clinic: Outpatient Rehabilitation Facility
• TOB 75 - Clinic: Comprehensive Outpatient Rehabilitation Facility (CORF)
• TOB 76 - Clinic: Comprehensive Mental Health Clinic
• TOB 79 - Clinic: Other
• TOB 81 - Special Facility: Hospice Non-Hospital
• TOB 82 - Special Facility: Hospice Special Facility: Hospice Hospital
• TOB 83 - Special Facility: Ambulatory Surgical Center
• TOB 85 - Primary Care Hospital
• Submission for Request for Anticipated Payment [RAP] claims (TOB=322 and 332)
• All Part A Claims
• All Part B Claims
• All DMERC Claims
• All Part A/RHHI Providers
• The claim contains only PQRI codes
• Sanctioned provider claim during service dates indicated
• Claim transferred for Medicaid quality project purposes only
• Recovery audit contractor (RAC)-initiated adjustment
• Individual COBA ID did not have a matching COIF
• Claim already utilized in another current CWF application or process
• Beneficiary identified on Medigap insurer eligibility file; duplicate Medigap claim-based crossover
• Claim submitted on 4010A1 file
• Claim submitted on 5010 file
• NCPDP claim submitted on D.0 file
• NCPDP claim submitted on 5.1 file