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September 2013

New guidelines established for processing Medicare primary claims

Starting Oct. 13, 2013, Blue Cross Blue Shield of Michigan will change how Medicare primary claims are processed. The changes will align with the policies of the Blue Cross Blue Shield Association.

BCBSA requires a minimum 30-day waiting period after the Medicare remittance date before a Blues plan can accept or process provider-submitted supplemental claims that involve Medicare crossover.

Medicare primary claims are submitted to Medicare for processing and then forwarded to a secondary insurance carrier via a crossover arrangement for additional payment determinations.

Providers can identify Medicare crossover claims that have been sent to BCBSM by looking for remittance advice remark codes MA18 and N89.

As a result of the changes, we’ll reject provider-submitted claims that include the following:

  • They feature remark codes MA18 or N89, indicating that Medicare crossover occurred.
  • They were received within 30 calendar days of the Medicare remittance date.
  • They were received with no Medicare remittance date.
  • They were received with a GY modifier on some lines, but not all. (The GY modifier is used to indicate that a code is statutorily excluded by Medicare.)

The new processing method for Medicare primary claims has additional guidelines. For statutorily excluded services and pricing issues with Medicare crossover claims, it’s important to note:

  • Providers who offer statutorily excluded services must indicate these services by using a GY modifier at the claim line level. This is a new requirement that will impact both professional and facility claims.
  • Providers can only submit statutorily excluded service lines on a claim. They can’t combine those lines with other services.
  • If a provider submits a claim to Medicare with both paid and excluded lines, the home plans will deny the excluded lines on the crossover claims and instruct the provider to resubmit those lines to their local plan. (A home plan is the Blues plan in which the member is enrolled.)
  • Providers will no longer have to submit known statutorily excluded services first to Medicare for consideration.
  • Providers will submit statutorily excluded service claims directly to the host plan, which is the plan serving the area where the Blues member received health care services.
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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
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