What is a crossover claim?

A crossover claim specifically refers to a situation where a medical service has been billed to one payer, in this case, Medicare, and subsequently, the claim is processed by a secondary payer, such as a Medicaid program. This process is essential because patients who are dual-eligible for both Medicare and Medicaid may receive services covered under both programs, leading to the need for coordination between the two insurance providers.

When a bill is first submitted to Medicare, it may partially cover the charges based on its reimbursement rules. Any remaining balance may then be submitted as a crossover claim to Medicaid to cover additional costs or copayments. This ensures that patients receive the benefits they are entitled to without facing out-of-pocket expenses for amounts that should be covered by their secondary insurance.

Understanding crossover claims is crucial in healthcare administration, as this system ensures efficient billing and payment processes, improves patient access to necessary healthcare services, and streamlines the financial aspects of healthcare management.