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Medicare/Medicaid Crossover Claims

If the information below does not answer your question, please call the TennCare Cross-Over Claims Provider Hotline at: 1-800-852-2683.

Crossover Claims Fee Schedule is: 85% of 2008 Medicare for Part B and 100% of 2008 Medicare for Part A.

Would having your paper claim processed in a timely manner make life easier?

UB 04's

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

  • When submitting paper claim, submit original claim form (pdf, 156kb) for processing

    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. Sample Form (pdf, 156kb)


    Claims must be submitted on a CMS approved claim form. Refer to CMS Manual System, Transmittal 1104 (pdf, 2,718kb), dated November 3, 2006 for the UB-04 Printing Standards. Compliance with these standards is required to facilitate the use of image processing technology. The attached claims are being returned as they do not meet these standards and/or do not have the ATTESTATION printed on the back of the form.


  • No copies submitted for processing (see example (pdf, 156kb))
    • Black and white copies cause data entry errors and alignment issues
  • Supply all data in a legible manner on the claim form in accordance with billing guidelines...

HCFA CMS -1500 (02-12’s)

Helpful reminders to avoid errors and delays when submitting a paper claim... (see instruction manual)

  • Include a copy of your Medicare EOMB and TPL EOB if applicable.
  • Form locator 17 b - NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN numbers.
  • Form locator 24 J - NPI Only/ Blank- Please do not report any legacy Provider Numbers, 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 (pdf, 137kb)

If things go wrong as they sometimes do, then follow the instructions on the second page/back of the Adjustment Form

UB 04 CHEAT SHEET

 

Form Locator Field Information
1 Provider Name, Address and Telephone Number Required. Enter the provider's Name, Address (including Zip code) and telephone number
2 Pay-to Name and Address Self explanatory
3a Patient Control Number Assigned by provider or facility
3b Medical/Health Record Number Assigned by patient's medical/health record
4 Type of Bill 4 digits. First digit as zero. (Swing bed is 0111).  Pages 16 to 19.
5 Federal Tax Number The number assigned to the provider by the federal government for tax reporting purposes. Also known as a tax identification number (TIN) or employer identification number (EIN).
6 Statement Covers Period Span dates
8a Patient Name/Identifier Enter patient's social security number or ID
8b Patient Name/Identifier Enter patient's name: last (suffix if applicable), first, middle initial
9 Patient Address (a.) Street/mailing address, (b.) City, (c.) State, (d.) Zip code (e.) Country Code (if other than USA)
10 Patient Birth date MMDDYYYY (example 12311921)
11 Patient Sex M = Male, F = Female, or U = Unknown
12 Admission/Start of Care Date Date of admission MMDDYY
13 Admission Hour 2 digit code to identify hour. Page 29
14 Priority (Type) of Visit Provider will select 1 digit. Page 30
15 Source of Referral for Admission or Visit Source code Page 32 - 34
16 Discharge Hour 2 digit code to identify hour. Page 35
17 Patient Discharge Status Indicates the patient status upon discharge. (EXAMPLE: Deceased enter Status Code 20 and Date of Death) Page 37 - 39
18-28 Condition Codes Enter "81" for Outpatient or "82" for Inpatient
29 Accident State N/A
31-34 Occurrence Codes and Dates Enter "53" and the Medicare Paid date. Pages 65 - 70
38 Responsible Party Name and Address Enter: Tennessee Medicaid , PO Box 480, Nashville, TN. 37202-0480 For Crossover Billing
39-40 Value Codes and Amounts Enter Value Code A1 for Deductible (07 is not valid) + $ amount
Enter Value Code 06 for blood deductible + $ amount
Enter Value Code 08 for Lifetime Reserve Days + $ amount
Enter Value Code 09 or A2 for Part B Co-insurance + $ amount (FOR THE FOLLOWING Enter; value code and the number of days)
Enter Value Code 80 for Covered Days
Enter Value Code 81 for Non-Covered Days
Enter Value Code 82 for Co-insurance Days
Enter Value Code 83 for Lifetime Reserve Days(Pages 77 - 91)
42 Revenue Code 4 digits, 0001= total line for all charges
43 Revenue Description Self explanatory
44 HCPCS/Rates/HIPPS Rate Codes digits must correspond w/rev. code in fl.42-44
45 Service Date MMDDYY
46 Service Units Must be more than zero. Total number of units per line. (one days is one unit for accommodation claims)
47 Total Charges Self explanatory
48 Non-covered Charges Self explanatory
50 Payer Name A = Primary Payer; (Medicare or HMO)
B = Secondary Payer; (Medicaid or TPL, if TPL exist)
C = Tertiary Payer; (Medicaid if TPL exist)
51 Health Plan Identification Number A = Primary Payer (Medicare or HMO)-State Medicare whether the primary payer is Traditional Medicare or a Medicare Advantage
B = Secondary Payer (Medicaid or TPL, if TPL exist
B = Secondary Payer (Medicaid or TPL, if TPL exist)
C = Tertiary Payer (Medicaid if TPL exist)
52 Release of Information Certification Indicator Indicates if a Consent statement signed was by provider
53 Assignment of Benefits Certification Indicator "N" = No, "Y" = Yes & "W" = N/A
54 Prior Payments - Payer Medicare payment amount on Medicare line (do not add contractual adjustment) (If there is a TPL the amount they paid should be on the TPL's line.)
55 Estimated Amount Due - Payer Total due from Medicaid (on Medicaid line)
56 National Provider Identifier - Billing Provider 10 digit NPI number
57 Other Provider Identifier Provider ID number assigned by Health Plan
58 Insured's Name (Medicaid Line) -Patient name as it appears in our system ( no titles or prefixes)
59 Patient's Relationship to the Insured 2 digit code. Page 169
60 Insured's Unique Identification (Medicaid Line)  -Patient Medicaid ID or SS#
61a Group Name Payer Name
62 Insurance Group Number N/A
63 Treatment Authorization Code (Prior Authorization # - N/A for Crossovers)
64 Document Control Number  
66 Diagnosis and Procedure Qualifier 9 for  ICD -09 Codes
67 Principal Diagnosis Code

And Present on Admission (POA) Indicator
1- 7 digit for ICD code. ICD -09 Code. No decimal necessary

8th digit Provider must enter "Y" for yes, "N" for no, "W" Clinically Undetermined, and "U" for No information in the record
67A-Q Other Diagnoses Codes ICD -09 Code. No decimal necessary
69 Admitting Diagnosis ICD -09 Code. No decimal necessary
70a-c Patient's Reason for Visit For Outpatient claims only. ICD -09 Code. No decimal necessary
71 Prospective Payment System (PPS) Code Not Required for Crossover Claims
72a-c External Cause of Injury (ECI) Code External Cause of Injury  ICD -09 Code. No decimal necessary
74 Principal Procedure Code and Date ICD -09 Code. No decimal necessary. Enter date as MMDDYY
74a-e Other Procedure Codes and Dates ICD -09 Code. No decimal necessary. Enter date as MMDDYY
76 Attending Provider Name and Identifiers NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers
77 Operating Physician Name and Identifiers NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers
78-79 Other Provider Name and Identifiers NPI Only/ Blank- Please do not report any legacy Provider Numbers, UPIN or licensure numbers

For information on how to file an appeal for a Medicaid Crossover Claim click here.