Medicare/Medicaid Crossover Claims

The Division of TennCare is pleased to announce that all institutional and professional Fee-For-Service Medicare crossover claims will be transitioned to TennCare’s existing Managed Care Organizations (MCO); Wellpoint (formerly known as Amerigroup), BlueCare, and UnitedHealthcare for adjudication. TennCare will no longer process Medicare crossover claims with dates of service on or after the transition go-live date of 1/1/2024.

What does this mean for me?

  • Nothing is changing with the current process. Everything that is done today by providers on submitting Medicare crossover claims to TennCare will continue for claims with dates of service up to 12/31/2023.
  • After the 1/1/2024 go-live date, COBA and the DSNPs will submit Medicare crossover claims to the member’s assigned MCO for processing and adjudication.
  • TennCare will continue to accept claims with dates of service through 12/31/23 as well as handling adjustments and voids with dates of service prior to 12/31/23.
  • The MCOs will communicate additional details on the transition in the upcoming months.

We look forward to the transition of Medicare crossover claims processing to the MCOs as it will create an operating model that supports TennCare’s managed care approach and increases claims processing operational efficiency.

If the information provided below does not answer your question, please call the TennCare Cross-Over Claims Provider Hotline at: 1-800-852-2863 for claims having dates of service prior to January 1, 2024. Please contact the member assigned Managed Care Organization for an Inquiry of claims submitted for dates of service on and after January 1, 2024.

Per Federal Regulations, as defined in 42CFR 455.410(b). All Providers reported on Medicaid/TennCare claims, whether the provider is a Billing or Secondary provider must be registered as a TennCare provider. Please be advised that electronic claims containing providers who are not registered will be denied and paper claims will be returned unprocessed to the submitter.

Crossover Claim Pricing Methodology: For Part A, rates obtained from the Medicaid State Plan less Medicare paid amount and TPL. For Part B, rates obtained from applying the logic outlined in Rule 1200-13-17.

All claims must be submitted on a CMS approved claim form.

Crossover Claims Process Guide

Helpful hints to avoid errors that cause delays when paper claims are submitted for processing.

  • When submitting paper claim, submit original claim form for processing.
  • A copy of the Medicare EOB (and TPL EOB if applicable) is required. Claims received without a Medicare EOB will not be processed and returned to the provider.

    UB-04 NOTICE: The submitter of this form understands that misrepresentation of falsification of essential information as requested by this form may serve as the basis for civil monetary penalties and assessments and may upon conviction include fines and/or imprisonment under Federal and/or State Laws.

    For NUBC the official site is http://www.nubc.org/ where you can purchase a manual or you can use a vendor to access the manual.
  • Supply all data in a legible manner on the claim form in accordance with billing guidelines.

Helpful reminders to avoid errors and delays when submitting a paper claim. (see National Uniform Claim Committee (NUCC) instruction manual)

  • A copy of the Medicare EOB (and TPL EOB if applicable) is required. Claims received without a Medicare EOB will not be processed and returned to the provider.
  • Form locator 17 b - NPI Only/ Blank- Please do not report any Medicaid Provider Numbers and/or UPIN numbers.
  • Form locator 24 J - NPI Only/ Blank- Please do not report any Medicaid Provider Numbers and/or UPIN numbers.
  • Form Locator 32 - Service Facility Location
    • 32 a - Enter the NPI #.
    • 32 b - Enter the two digit qualifier identifying the non-NPI number followed by the ID number.
  • Form Locator 33 - Billing provider Info and phone number
    • 33 a - Enter NPI of the billing provider.
    • 33 b - Enter the two digit qualifier identifying the non - NPI number followed by the ID #.
  • NOTICE: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal and State laws. Sample Form

Adjustment/Void Forms are for use when either changes to a paid claim are required or when it is necessary to void a paid claim PLEASE NOTE: Denied claims cannot be adjusted or voided.

Instructions on how to fill out an Adjustment/Void Form are located on the second page/back of the Adjustment Form

Adjustment Form for Medicare/Medicaid claims

TennCare/Medicaid is always the last payer source, so when there is a Third Party Liability (TPL) involved, you must complete the following TPL Override Form in order for the claim to adjudicate.

For information on how to submit a Crossover Claims Reprocess Request.