- Introduction
- About Provider Outreach and Education
- ABN for Not Reasonable and Necessary Denials
- Appeals/Reopenings
- Assignment of Benefits
- Comprehensive Error Rate Testing
- CMS-1500 Claim Form
- Deceased Beneficiary Claims
- Electronic Data Interchange
- Evaluation and Management Services
- Fraud and Abuse
- Health Professional Shortage Area
- Hospice
- Limiting Charge
- Medical Policy Development
- Medigap
- Modifiers
- Nonphysician Practitioners
- National Provider Identifier
- Participation Program
- Payment Floor Standards
- Provider Enrollment
- Refunds and Overpayments
- Ordering and Referring Claims Information
- Return/Reject
- Standard Remittance ANSI Codes and Remittance Advice
- Appendix 1: Forms
- Appendix 2: Glossary
- Appendix 3: Place of Service Codes
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
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.
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.
| Code | Description |
|---|---|
| Item 9 | Enter the last name, first name, and middle initial of the enrollee in the Medigap policy, if it is different from the name in Item 2. Otherwise, enter “same” (see Item 9d). |
| Item 9a | Enter the policy and/or group number of the Medigap enrollee preceded by the word Medigap, MG or MGAP (see Item 9d). |
| Item 9b | Leave Blank ‒ this field is reserved for NUCC use. |
| Item 9c | Leave blank if item 9d is completed. Otherwise, enter the claims processing address of the Medigap insurer. Use an abbreviated street address, two-letter postal code and ZIP Code copied from the Medigap insured’s Medigap identification card. For example: Anywhere Street, Maryland 21204. |
| Item 9d | Under CMS’ national COBA claim-based Medigap process, participating providers and suppliers that are exempted under the ASCA from having to bill electronically will be required to enter the CMS-assigned five-digit claim-based Medigap COBA ID in Item 9d. Otherwise, we cannot forward the claim information to the Medigap insurer via the COBA claim-based Medigap crossover process. For more information, refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 28. |
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.
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.
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.
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.
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 9/29/2023