Third-party Liability: Payment Limitations on Medicare Crossover Claim Submissions

(A) A crossover is defined as a claim for a member who has Medicare in addition to MassHealth, where Medicare has made a payment or has approved an amount that was applied to the member’s deductible. (B) To obtain crossover payment, a provider must (1) bill the Medicare fiscal intermediary or carrier, as applicable, in accordance with their billing rules, including using the appropriate Medicare claim form and format; (2) accept assignment according to Medicare instructions; and (3) follow the MassHealth agency’s billing instructions relating to crossover claims. 3. Billing Regulations (130 CMR 450.000) (C) Unless specifically provided for in law or by contract or interagency service agreement with the MassHealth agency, the MassHealth agency is not liable for payment of a service for which a member is not liable, including, without limitation, services available through an agency of the local, state, or federal government, or through a legally obligated person or entity. (D) The MassHealth agency’s crossover liability will not exceed (1) the member’s liability including coinsurance, deductibles, and copayments as reported on the explanation of benefits or remittance advice from Medicare; (2) the maximum allowable amount payable under the MassHealth agency’s payment methodology; or (3) the MassHealth agency’s established rate for crossover payment. (130 CMR 450.319 and 450.320 Reserved)