(Medicare Claims Processing Manual)

Participating providers and suppliers that must bill electronically shall enter the 5 -digit claim- based Medigap COBA ID in field NM109 of the NM1 segment in loop 2330B of the Health Insurance Portability and Accountability Act (HIPAA) ASC X12 837 professional claim for purposes of triggering Medigap clai m-based crossovers.  If a participating Part B physician/practitioner or DMEPOS supplier fails to include this identifier in the field just described, the claim will not be transferred, as appropriate, to the Medigap insurer via the COBA claim -based Mediga p crossover process.   Under CMSs national COBA claim -based Medigap process, participating Part B physicians/practitioners and suppliers that are exempted under the Administrative Simplification Compliance Act (ASCA) from having to bill electronically are required to enter the CMS -assigned 5- digit claim- based Medigap COBA ID on the paper form.   Medigap information is entered on the CMS Form 1500 as follows:   Version 08/05  Item 9a  - The policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.  Note -  item 9d must be completed if a policy and/or group number is entered in item 9a.  Item 9b  - The Medigap insureds 8- digit date of birth (MM|DD|CCYY) and sex.  Item 9c -  Blank if item 9(d) is completed.  Otherwise, the claims processing address of the Medigap insurer.  An abbreviated street address, two -letter postal code, and ZIP Code copied from the Medigap insureds Medigap identification card is entered. For example :  1257 Anywhere Street  Baltimore, Md. 21204 Is shown as  1257 Anywhere St. MD 21204   Item 9d  - Enter the Coordination of Benefits Agreement (COBA) Medigap claim -based Identifier (ID).  Refer to chapter 28, section 70.6.4, of this manual for more informati on.  All the information in items 9, 9a, 9 b, and 9d must be complete and accurate.  Otherwise, the A/B MAC (B) or DME MAC cannot forward the claim information.  Version 02/12  Item 9a  - Enter the policy and/or group number of the Medigap insured preceded by MEDIGAP, MG, or MGAP.   Note -  item 9d must be completed if a policy and/or group number is entered in item 9a.  Item 9b  - Leave blank.   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 insureds Medigap identification card. For example:   1257 Anywhere Street  Baltimore, M d. 21204 Is shown as  1257 Anywhere St. MD 21204  Item 9d  - Enter the Coordination of Benefits (COBA) Medigap claim -based identifier (ID).  See Chapter 28, 70.6.4 for more information.  All the information in items 9, 9a, and 9d must be complete and accurate.  Otherwise, the A/B MAC (B) or DME MAC cannot forwar d the claim information.   Retail pharmacies that wish to trigger claim- based crossovers to Medigap insurers shall enter the Medigap claim -based COBA ID within field 301- C1 of the T04 segment of the NCPDP claim.  30.2 - ASC X12 837 Institutional/Form CMS -1450 COB  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  In accordance with the language provided within 1842(h)(3)(B) of the Social Security Act, no information entered on an incoming Form CMS -1450 or incoming Health Insurance Portability Act (HIPAA) ASC X12 837 institutional claim (current format) shall result in a process whereby CMS transfers the claim to a Medigap insurer.   40 - MSN Messages (Rev.  4069, Issued: 06- 08  18, Effective: 07 - 09- 18, Implementation: 07-  09-18)  A Medicare beneficiary who has a Medigap policy may authorize the participating physician/practitioner or supplier of services to file a claim on his or her behalf and to receive payment directly from the insurer instead of through the beneficiary.  In such cases, Medicare must transfer Medicare claims information to the Medigap insurer.  The Medigap insurer pays the physician/provider/supplier directly.  The Medigap insurer, in turn, reimburses CMSs designated COBA contractor for the costs in supplying the  information subject to limitations.    Paid claims from participating physicians or providers/suppliers for beneficiaries who have assigned their right to payment under a Medigap policy, regardless of whether or not it is in or from a State with an approved Medigap program, are to result in the transfer of claim information to the specified insurers.  The A/B MAC ( Part B) and DME MAC systems must have the capability to distinguish between claims of participating and nonparticipating physicians/practitioners and suppliers. This is because Medigap assignment of claims and transfer policy does not apply to nonparticipating physicians/practitioners or non-participating suppliers.   Effective with the future implementation of CMSs consolidated Medigap claim- based crossover initiative, the process for reporting Medigap information on incoming claims will change.  Each Part B physician/practitioner and supplier of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) will only include the C MS-issued Medigap claim -based COBA ID  (ID range 55000 through 55999), which will be assigned by CMSs Benefits Coordination & Recovery Center (BCRC) , if: (1) the physician/practitioner or supplier participates in the Medicare Program; and ( 2) the benefici ary has assigned his/her rights to payment under a Medigap policy to that provider or supplier.   50 - Remittance Notice Messages  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  All A/B MACs  and  DME MACs shall include the following message on remittance notices sent to participating physicians/practitioners and suppliers when Medigap benefits are assigned and the information in block #9 of the Form CMS -1500 (or FL50 of the Form CMS -1450, as appropriate) is completed:   MA 18  The claim information is also being forwarded to the patients supplemental insurer.  Send any questions regarding supplemental benefits to them.   If the information in block #9 of the Form CMS -1500 or FL50 of the Form CMS -1450 is incomplete, or more than one Medigap insurer was entered, MACs do not transmit a transaction record to the Medigap insurer. In such cases, the following message is included on the remittance advices.   MA19 -  Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning the insurer. Please verify your information and submit your secondary claim directly to that insurer.   Beginning with the October 2004 systems release, all A/B MACs and DME MACs   shal l include COBA trading partner names on the provider Electronic Remittance Advice (ERA) following receipt of a Beneficiary Other Insurance (BOI) reply trailer 29.  (See 70.6 of this Chapter for more details.)   60 - Returned Medigap Notices  (Rev.  4069, Issued: 06- 0818, Effective: 07 -09-18, Implementation: 07-  09-18)   A/B MACs ( Part B) and DME MACs ceased this responsibility on October 1, 2007, when CMSs BCRC assumed full responsibility for the COBA claim- based Medigap process.   70 - Coordination  of Medicare With Medigap and Other Complementary Health Insurance Policies  (Rev. 4069, Issued: 06- 0818, Effective: 07 -09-18, Implementation: 07- 09-18)  For applicable policy on information sharing, see Pub 100- 1, the Medicare General Information, Eligibi lity and Entitlement Manual, Chapter 6.   For applicable cost sharing policy, see Pub 100- 06, the Medicare Financial Management Manual, Chapter 1.    Cost Calculation Process Leading Up to the BCRCs  Assumption of Claim-Based Medigap Crossovers  Up to and including the final claims transferred under their pre-existing mandatory Medigap (claim- based) crossover processes (note:  the final claims should be those processed by the A/B MAC ( Part B) or DME MAC just before the October 2007 release is installed), A/B MACs ( Part B) and DME MACs should determine the frequency at which they routinely transmit notices to all Medigap insurers but must transmit not less often than monthly. (See 70.4)  Effective October 1, 2005, CMS fully consolidated the eligibility file- based claims crossover process, as it relates to Medigap insurers and other commercial payers, under the BCRC.  Refer to 70.6 and succeeding sub-sections for A/B MAC ( Part B) and DME MAC requirements and responsibilities relating to the national Coordination of Benefits Agreement (COBA) consolidated crossover process.  Refer to 70.6.4 for all MAC requirements relating to the COBA Medigap claim-based crossover process, whic h was inaugurated on October 1, 2007.  (See also Pub.100-04 chapter 27 80.7.)  Following crossover consolidation, all A/B MACs ( Part B) and DME MACs shall continue to pursue collection of unpaid debts from Medigap insurers and other existing trading partners, even after such entities have been transitioned to the COBA process.  Those MACs that maintained claim- based crossover arrangements with Medigap insurers shall pursue collection of their invoices up through and including their invoices for the final claims transfer to the Medigap entities.  These invoices should have been issued no later than one (1) month following the last claims transfer to the Medigap insurers.  Suppression of Sanctioned Provider Claims from Claim- Based Medigap Crossovers   Effectiv e with April 2, 2007, all A/B MACs ( Part B) and DME MACs shall suppress fully denied provider sanctioned claims for their mandatory Medigap crossover process with Medigap insurers, as authorized by 1842(h)(3)(B) of the Social Security Act and 4081(a)(B) of the Omnibus Budget Reconciliation Act of 1987 [Public Law 100-230].  NOTE:   All A/B MACs ( Part B) and DME MACs shall continue to suppress 100 percent paid and 100 percent denied claims from their mandatory Medigap crossovers, per previous CMS guidance.  70.1 - Authorization for Release of Information  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)   See Pub 100-01, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 6.  70.1.1 - Requests for Additional Information  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)  In the absence of a standing arrangement, the mere presence of an authorization to release and the identification of a complementary insurer on a title XVIII billin g form does not constitute a request for the release of information.  The request for the information must be specific.  70.1.2 - Release of Title XVIII Claims Information for Medigap Insurance Purposes by Providers  (Rev. 2906, Issued: 03- 14-14, Effectiv e: 04 -14-14, Implementation 04-14-14)  Subject to specific written beneficiary authorization, providers, physicians/practitioners, and suppliers are permitted to furnish certain limited information about Medicare eligibility status and related claims information to other payers for complementary insurance purposes.  (See Chapter 6 of Pub 100-01, the Medicare General Information, Eligibility, and Entitlement Manual.)    70.2 - Integration of Title XVIII Claims Processing With Complementary Insurance Claims Processing (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  General