UB 04 Medicare Crossover for Other Blue Plan Members
Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:
Form Locator 50 – Payer
• Enter “Medicare” as the primary payer on line A.
• Enter the appropriate Blue Plan name as the secondary payer on line B.
o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.
o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.
Form Locator 53 – ASG BEN
• A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.
• This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.
• The member or representative’s signature must be on file as a separate Medigap authorization.
• The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.
Form Locator 54 – Prior Payments
• Enter the amount you have received toward payment of this bill from Medicare on line A.
Form Locator 58 – Insured’s Name
• Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.
Form Locator 59 – P. Rel
• Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).
Form Locator 60 – Insured’s Unique ID
• Enter the patient’s Medicare HIC number as shown on the ID card on line A.
• Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
Form Locator 61 – Group Name
• Enter the name of the group or plan through which the insurance is provided to the member.
Form Locator 62 – Insurance Group No.
• Enter the group number as identified on the ID card.
Completing a claim correctly when a member from another Blue Cross and/or Blue Shield Plan has primary coverage with Medicare will decrease your chance of receiving claim denials. The following instructions apply to items on the UB-04 form or its electronic counterpart that require specific Medicare Supplement information:
Form Locator 50 – Payer
• Enter “Medicare” as the primary payer on line A.
• Enter the appropriate Blue Plan name as the secondary payer on line B.
o Not entering the member’s actual Blue Plan as the correct secondary payer will result in claim issues. A claim crossed over in error to BCBSF cannot be processed and you may not receive a remittance notice. Therefore, be sure to enter the correct Blue Plan when you submit the claim to Medicare. If your system is set-up to automatically populate BCBSF, please change it to the correct Blue Plan.
o If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the alpha prefix and you will be routed to the member’s Blue Plan.
Form Locator 53 – ASG BEN
• A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.
• This indicator authorizes payment of mandated Medigap benefits to you if required Medicare Supplement information is included on the claim.
• The member or representative’s signature must be on file as a separate Medigap authorization.
• The Medigap assignment on file must specify the insurer. It may state that the authorization applies to all occasions of service until it is revoked.
Form Locator 54 – Prior Payments
• Enter the amount you have received toward payment of this bill from Medicare on line A.
Form Locator 58 – Insured’s Name
• Enter the last name, first name and middle initial of the insured. The name must be entered exactly as it is on the ID card.
Form Locator 59 – P. Rel
• Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).
Form Locator 60 – Insured’s Unique ID
• Enter the patient’s Medicare HIC number as shown on the ID card on line A.
• Enter the patient’s complete Blue Plan ID number, including three-digit alpha prefix on line B. Member IDs for other Blue plans include the alpha prefix in the first three positions and can contain any combination of numbers and letters up to 17 characters.
Form Locator 61 – Group Name
• Enter the name of the group or plan through which the insurance is provided to the member.
Form Locator 62 – Insurance Group No.
• Enter the group number as identified on the ID card.