What is a Crossover Only Application?

Having both Medicare and Medicaid coverage can get confusing when it comes to filing insurance claims and getting paid. This is where a crossover only application comes in. But what exactly does this term mean?

Below we’ll explain what a crossover only provider application is, who needs it, and how the claims crossover process works for those with dual eligibility.

What is a Crossover Claim?

First, let’s define what a crossover claim is.

Crossover claims refer to medical claims for someone who has both Medicare and Medicaid (dual eligible individual) that get crossed over from Medicare to Medicaid to coordinate benefits.

Here’s an overview of how it works:

• Patient receives medical services and provider bills Medicare

• Medicare processes the initial claim as the primary payer

• Any unpaid balance left after Medicare’s payment “crosses over” to Medicaid

• Medicaid processes the outstanding amount as the secondary payer

The goal is to have the two programs coordinate so providers get fully reimbursed for services to dual eligibles. This prevents balance billing the patient.

What is a Crossover Only Provider?

Now let’s discuss what a crossover only provider is.

A crossover only provider refers to a medical provider who sees dual eligible patients but is not enrolled as a regular Medicaid provider.

They only want to file crossover claims to get the balances paid after Medicare’s portion. They don’t intend to file direct Medicaid claims.

Some common examples include:

• Specialists who mainly treat Medicare patients
• Out-of-state providers near borders
• Providers who rarely see Medicaid patients

Without crossover only status, these providers can’t file the secondary Medicaid portion of claims for duals. This could leave them unable to be paid fully.

What is a Crossover Only Application?

A crossover only application is a form a provider completes to apply for crossover only status with the state’s Medicaid program.

The application allows them to participate in the claims crossover process despite not being an enrolled Medicaid provider.

Each state has its own version of the crossover only application form and requirements. They typically request basic information like:

• Provider name, NPI number, specialty, contact info
• Tax ID numbers
• Medicare billing details
• Medicaid provider ID if enrolled in other states
• Signature attesting to accuracy

The Centers for Medicare and Medicaid Services (CMS) recommend states allow crossover only enrollment to facilitate coordination of benefits for dual eligibles.

Without it, providers have no way to file the Medicaid portion of crossover claims. This could deter them from seeing dual patients.

Why Crossover Only Status is Needed

There are a few key reasons why providers need to file for crossover only status:

• To prevent patient balance billing – Without it, dual patients may get billed unpaid Medicare balances

• To coordinate dual benefits – It allows the automated crossover process to function smoothly

• To get fully reimbursed – Ensures providers receive Medicaid’s portion of payment

• To comply with rules – States require crossover only enrollment to file secondary claims

• To aid Medicare beneficiaries – Gives Medicare-focused providers an avenue to see dual patients

• To improve access to care – More providers willing to accept dual eligible patients

Who Needs to Submit a Crossover Only Application?

Which types of providers need to complete the crossover only application in their state?

In general, any Medicare-enrolled provider who sees dual eligible patients but is not a fully participating Medicaid provider needs crossover status.

Some examples include:

• Specialists like surgeons, cardiologists, neurologists
• Out-of-state providers located near state borders
• Primary care physicians who rarely see Medicaid patients
• Psychiatrists and mental health providers
• Small independent private practices
• Solo practitioners

Even providers who only occasionally treat dual eligible individuals likely need crossover only status for those rare instances.

Any Medicare provider that wants to file the secondary Medicaid portion of a claim for a dual needs to apply.

How the Crossover Claims Process Works

Now let’s walk through how the full coordinated crossover claim process works step-by-step:

1. Patient receives services – For example, a dual Medicare/Medicaid patient sees a cardiologist for an annual check-up.

2. Provider bills Medicare – The cardiologist bills Medicare as primary payer.

3. Medicare processes claim – Medicare reviews the claim and determines approved reimbursement amounts based on Medicare rates.

4. Medicare pays portion – Medicare pays its approved reimbursement amount to the provider.

5. Claim crosses over to Medicaid – Any unpaid balance automatically gets forwarded to Medicaid electronically.

6. Medicaid processes balance – Medicaid reviews the crossover claim and pays the secondary balance per Medicaid guidelines.

7. Provider receives payment – The cardiologist gets the Medicaid payment for the remainder owed.

8. No balance billing – The provider cannot bill the patient any outstanding amount.

This automated process allows fast coordinated claims payment without the need for providers to file the Medicaid portion separately. The provider gets seamlessly reimbursed.

How Providers Submit Crossover Only Applications

The process for submitting crossover only applications varies by state. Below are some common ways providers can apply:

• Through state Medicaid portal– Many states allow online application via the Medicaid provider portal.

• Fillable PDF form– Providers complete a printable PDF form and submit by email or mail.

• Paper application – Some states still use a paper crossover only application that must be mailed in.

• Fax – In some cases the application can be faxed with supplemental documents.

• E-mail – Certain states allow scanned applications to be emailed.

• Enrollment broker – States that use Medicaid enrollment brokers may direct providers to submit through them.

Each state website should outline the current process to apply. Supporting documents like W9s may need to be attached.

Crossover Only Application Processing Times

How long does it take to get approved for crossover only status? Approval times also depend on the state:

• Same day to 1 week – Some states process applications very quickly in just a few days.

• 1-2 weeks – More commonly it takes 1-2 weeks for approval.

• 30 days – Federal guidelines recommend states approve or deny within 30 days.

• 45-60 days – Some states take 45 days or longer for crossover only decisions.

Once approved, providers can immediately begin filing crossover claims for dual patients. Approved status must be renewed periodically, like every 1-3 years.

Denied Crossover Only Applications

If a crossover application is denied by the state, here are common reasons why:

• Incomplete application – Missing signatures, forms, or required information

• Disqualified provider – Certain types like adult day care centers may not qualify

• Medicare opt-out – Provider isn’t enrolled or opted out of Medicare

• Under investigation – Recent disciplinary actions may result in denial

• Unpaid Medicaid debts – Past Medicaid overpayments not yet repaid

• Excluded providers – On state or federal excluded provider lists

If denied, the state will issue a denial letter explaining appeal rights. Providers may reapply after resolving the underlying issue for denial.

Key Takeaways

• Allows providers to file Medicaid crossover claims for duals

• Required for providers who see duals but aren’t Medicaid enrolled

• Helps coordinate benefits and prevent patient balance billing

• Each state has own application form and submission process

• Processing times range from same day to 30-60 days

• Denials can happen for issues like incomplete forms

• Approval must be periodically renewed, often every 1-3 years

Understanding the coordinated claims process is crucial for serving dual eligible patients. Completing the state crossover only application ensures providers can be reimbursed for Medicare cost-sharing amounts by Medicaid. This process prevents dual eligible patients from getting stuck with unexpected medical bills.