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Railroad Medicare
The Differences Between Crossover and Medigap

Crossover
Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and Health Insurance Claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

The first claim submitted to Railroad Medicare will not cross over. This is because your eligibility information must be added to Railroad Medicare's system. As long as your name and HIC number appear on a company's monthly crossover listing, Railroad Medicare will continue to forward claims information to the supplemental insurer.

Some supplemental insurers do not offer crossover. You should contact your insurance company to see if your policy is eligible for the crossover program.

Medicaid offers a crossover program with Medicare. The crossover list consists of eligible Medicaid recipients. However, if you are on crossover with a supplemental insurer, we will only forward information to the supplemental insurer, not to Medicaid. In order for you to be on crossover with Medicaid, you cannot be on crossover with any supplemental insurer. If you have both Medicare and Medicaid, your health care providers must accept assignment on all Medicare claims.

Medigap
Medigap is a health insurance policy or other health benefit plan offered by a private entity to people entitled to Medicare benefits. It is specifically designed to supplement Medicare benefits by filling in some of the 'gaps' that Medicare does not cover, such as deductibles, coinsurance amounts or other limitations. It does not include limited benefit coverage available to Medicare beneficiaries such as 'specified disease' or 'hospital indemnity' coverage. It explicitly excludes a policy or plan offered by an employer to employees or former employees as well as that offered by a labor organization to members or former members.

Medigap eliminates the need for you or your participating health care providers to file separate claims to Medigap insurers. Railroad Medicare will automatically send claim information to Medigap insurers, if you have elected to assign your Medigap benefits to a participating provider.

The Medigap plan differs slightly from the crossover process. In order for information to be forwarded to a Medigap insurer, the following criteria must be met:

  1. Physicians must be participating (PAR)
  2. The supplemental policy must meet the definition of a Medigap policy
  3. Physicians must include the following Medigap policy information on the CMS-1500 claim form or electronic claim:
    • Name of Medigap insurer (Item 9)
    • Enter the other insured's policy or group number preceded by MEDIGAP, MG OR MGAP (Item 9a)
    • Leave blank (reserved for NUCC use) (Item 9b)
    • Leave blank (reserved for NUCC use) (Item 9c)
    • Enter the Coordination of Benefits Agreement (COBA) Medigap-based Identifier (ID) (Item 9d)

 

last updated on 01/23/2014
ver 1.0.25