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Provider updates

Medicare Crossover Claims

Jun 26, 2019, 07:00 AM

CareOregon began receiving Medicare Crossover claims May 1, 2018. Some provider organizations have crossover claims that differ in either claim form type or billing NPI from what CareOregon receives from these same billing providers. If your organization is submitting different claim form types or billing NPIs to Medicare, it may conflict with CareOregon’s provider setup in our claims database. As a result, your organization may see rejections of Medicare Crossover claims.

These billing differences fall into two main categories: 

  • FQHCs and RHCs submitting UB04 claim forms to Medicare – if your organization submits claims on UBs to Medicare, but sends 1500s to CareOregon, we will begin issuing $0 payment on these UB claims with a remittance message N34 - Incorrect claim form/format for this service. Although OHA has updated their rules to allow these organization types to submit claims on UBs, CareOregon is unable to accommodate claims being submitted under both claim form types due to claim duplication risks.
  • Billing provider NPI inconsistencies – if your organization submits 1500 claim forms to Medicare with organization NPIs different from those being submitted to CareOregon, please know that you may receive a $0 payment with remit N257 – Missing/incomplete/invalid billing provider/supplier primary identifier. Per 5010 HIPAA Transaction Guidelines, if the organization health care provider has enumerated subparts (obtained clinic-level NPIs), then it is required that the subpart’s NPI be reported as the Billing Provider. The subpart reported as the Billing Provider must always represent the most detailed level of enumeration. And, the organization must use the same billing NPI for all the payers to whom you submit claims.

 If your organization receives remits on Medicare Crossover claims meeting one or both of the situations above, and you would like to update your billing configuration with CareOregon, please write with the details of your billing change and we will work with you to update our claims database if possible.

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