Mastering Medicare Secondary Payer UB-04 Claims: A Guide for Blue Cross Blue Shield Medicare Crossover

Learn how to accurately complete UB-04 claims for Medicare crossover with other Blue Plan members, avoiding denials and ensuring timely reimbursement. Detailed instructions for key form locators included.

Understanding Medicare Secondary Payer UB-04 and Blue Cross Blue Shield Medicare Crossover Claims

When a patient has Medicare as their primary insurance and a Blue Cross Blue Shield plan (or another Blue Plan) as their secondary coverage, the billing process involves submitting a Medicare secondary payer UB-04 claim. This is often referred to as a Blue Cross Blue Shield Medicare crossover claim. Correctly completing the Uniform Bill (UB-04) is crucial for healthcare providers to ensure accurate reimbursement and prevent claim denials. This guide provides detailed instructions to help you navigate the complexities of Medicare crossover billing for other Blue Plan members.

Coordination of Benefits Medicare and Blue Cross

Coordination of Benefits (COB) is essential when a patient has more than one health insurance plan. For Medicare and Blue Cross Blue Shield plans, it determines which plan pays first (primary payer) and which pays second (secondary payer). Medicare typically acts as the primary payer, especially for beneficiaries with Medigap policies or certain other group health plans. Understanding these rules is vital to correctly complete your Medicare secondary payer UB-04 claims.

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 Sample UB-04 Claim Form or its electronic counterpart that require specific Medicare Supplement information:

Form Locator 50 – Payer

Enter “Medicare” as the primary payer on line A. This identifies Medicare as the initial payer responsible for the claim.
Enter the appropriate Blue Plan name as the secondary payer on line B. This designates the Blue Plan as the secondary insurer that will pay after Medicare has processed its portion.

Why it’s important: 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 an incorrect Blue Plan 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 a default plan (e.g., BCBSF), please change it to the correct Blue Plan.

Tip: If you do not know the member’s Blue Plan, call BlueCard Eligibility at (800) 676-BLUE (2583), speak the Blue Cross Blue Shield Three-Digit Alpha Prefix and you will be routed to the member’s Blue Plan.

Form Locator 53 – ASG BEN (Assignment of Benefits)

A “Y “indicating benefits were assigned must be entered in order for you to receive payment from the Blue Plan.
Why it’s important: This indicator authorizes payment of mandated Medigap benefits directly to you, the provider, if required Medicare Supplement information is included on the claim. Without this ‘Y’ indicator, the payment may be sent to the patient instead.
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.
Why it’s important: This field ensures that the secondary payer (Blue Plan) is aware of the payment already made by Medicare, preventing overpayment and ensuring accurate coordination of benefits.

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.
Why it’s important: Accurate patient identification is critical for claims processing. Any discrepancy can lead to delays or denials.

Form Locator 59 – P. Rel (Patient Relationship to Insured)

Enter the appropriate code indicating the relationship of the patient to the insured (e.g., code 18 = self).
Why it’s important: This code establishes the patient’s relationship to the policyholder, which is essential for verifying coverage and eligibility under the Blue Plan.

Form Locator 60 – Insured’s Unique ID

Enter the patient’s Medicare Beneficiary Identifier (MBI) as shown on the ID card on line A.
Crucial Update: The Centers for Medicare & Medicaid Services (CMS) transitioned from Health Insurance Claim Numbers (HICNs) to MBIs. Using outdated terminology like HICN can lead to claim rejections. Always use the MBI for Medicare claims.
Enter the patient’s complete Blue Plan ID number, including Blue Cross Blue Shield 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.
Why it’s important: Providing correct and current identification numbers for both primary and secondary payers is paramount for claim matching and processing.

Form Locator 61 – Group Name

Enter the name of the group or plan through which the insurance is provided to the member.
Why it’s important: This helps the secondary payer identify the specific group policy under which the patient is covered.

Form Locator 62 – Insurance Group No.

Enter the group number as identified on the ID card.
Why it’s important: The group number is another critical identifier for the secondary insurance plan, ensuring the claim is processed against the correct policy.

Common Pitfalls and Errors in UB-04 Medicare Crossover Claims

Even with careful attention to form locators, providers often encounter specific challenges when submitting Blue Cross Blue Shield Medicare crossover claims. Avoiding these common errors can significantly reduce denials and speed up reimbursement:

Incorrect Blue Plan Identification: As noted in FL 50, submitting to the wrong Blue Plan is a frequent error. Always verify the specific Blue Plan (e.g., BCBS of Florida vs. BCBS of California).
Outdated Patient Identifiers: Failing to use the patient’s current Medicare Beneficiary Identifier (MBI) instead of the old HICN is a common cause for Medicare claim rejections.
Timely Filing Limits: Both Medicare and Blue Plans have strict timely filing limits. Ensure claims are submitted within these windows, including secondary claims after Medicare’s processing.
Missing or Incorrect Modifiers: Certain services or situations require specific modifiers on the UB-04. Incorrect or missing modifiers can lead to claim denials.
Patient Responsibility Issues: Clearly understanding and indicating patient responsibility (deductibles, co-pays, co-insurance) is essential. Misrepresenting these can cause billing discrepancies.
Incomplete Medigap Authorization: For FL 53, ensure the patient’s Medigap assignment is properly documented and on file to receive direct payment.

Frequently Asked Questions (FAQ) about UB-04 Medicare Crossover for Blue Plan Members

What happens if I submit to the wrong Blue Plan?: The claim will likely be denied or rejected by the incorrect Blue Plan, requiring you to resubmit it to the correct plan, which can delay reimbursement and potentially lead to timely filing issues.
How do I verify a patient’s Blue Plan?: Always use the BlueCard Eligibility line at (800) 676-BLUE (2583) and provide the Blue Cross Blue Shield Three-Digit Alpha Prefix from the patient’s ID card. This ensures you’re routed to the correct plan.
Is Medigap automatically assigned?: No, Medigap benefits are not automatically assigned to the provider. A separate authorization from the member or their representative is required, as noted for Form Locator 53.
Where can I find information on Medicare coordination of benefits explained?: For comprehensive guidance on how Medicare coordinates benefits with other payers, refer to official CMS resources. Understanding these rules is critical for accurate secondary billing.

Conclusion: Ensuring Accurate Blue Cross Blue Shield Medicare Crossover Claims

Accurately processing Blue Cross Blue Shield Medicare crossover claims on the Medicare secondary payer UB-04 form is fundamental for efficient reimbursement. By meticulously following these instructions, understanding the purpose of each form locator, and avoiding common pitfalls, providers can significantly reduce denials and streamline their billing process. Given that CMS and specific Blue Plan billing guidelines can change, it is paramount to stay updated with the latest requirements and resources to maintain compliance and financial health.