Blue Cross and Blue Shield Plans use the Centers for Medicare and Medicaid Services (CMS) crossover process to receive Medicare primary claims. The CMS crossover process routes Medicare Supplemental claims (Medigap and Medicare Supplemental) directly from Medicare to Blue Cross and Blue Shield of Texas (BCBSTX).
- Providers do not need to submit the claims to BCBSTX.
- Duplicate claims result when claims are submitted to both Medicare and BCBSTX.
When the Home Plan receives a Medicare Primary claim before it is crossed over, it may be incorrectly paid based on an estimated Explanation of Medicare Benefits (EOMB).
- Provider payment should be based on the actual EOMB not an estimated EOMB.
- Duplicate claims may cause incorrect member cost share calculations when estimated EOMB is used.
How do I submit a claim when Medicare is primary and Blue Plan is secondary?
- Submit claims to your Medicare carrier when Medicare is primary, and the Blue Plan is secondary.
- When submitting the claim, enter the correct Blue Plan name as the secondary carrier. Check the member’s ID card for additional verification.
- Include the three-character prefix located on the members ID card.
When you receive the remittance advice from Medicare, determine if the claim has been automatically forwarded (crossed over) to the Blue Plan:
- Remark codes MA18 or N89 on the Medicare remittance indicate that the claim was crossed over. Do not resubmit that claim to BCBSTX.
- If the remittance indicates that the claim was not crossed over, submit the claim to BCBSTX with the Medicare remittance advice.
- The member ID card may include a Coordination of Benefits Agreement ID number, include that number on your claim.
Questions on the status of a claim?
- Electronically — send a HIPAA transaction 276 (claim status inquiry) to BCBSTX through Availity® or your preferred online vendor portal.
- Call our Interactive Voice Response (IVR) phone system at 1-800-451-0287.
When should I expect to receive payment?
Claims submitted to Medicare will be crossed over to the Blue Plan after they have been processed by the Medicare intermediary.
- This process takes 14 business days to occur. Medicare releases the claim to the Blue Plan.
- Allow 30 additional business days to receive payment or instructions from the Blue Plan.
What should I do in the meantime?
After submitting the claim to the Medicare carrier:
- Allow 30 calendar days from receipt of the Medicare Remittance advice.
- To avoid submitting a duplicate claim, check the status of the initial claim before resubmitting.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to Blue Cross and Blue Shield of Texas (BCBSTX). BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third-party vendors such as Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly