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Medicare/Medicaid Crossover Claims

If the information provided below does not answer your question, please call the TennCare Cross-Over Claims Provider Hotline at: 1-800-852-2683.

Per Federal Regulations, as defined in 42CFR 455.410(b) . All Providers reported on Medicaid/TennCare claims, whether the provider is a Billing or Secondary provider must be registered as a TennCare provider. Please be advised that electronic claims containing providers who are not registered will be denied and paper claims will be returned unprocessed to the submitter.

Crossover Claim Pricing Methodology: For Part A, rates obtained from the Medicaid State Plan less Medicare paid amount and TPL. For Part B, rates obtained from applying the logic outlined in Rule 1200-13-17.

All claims must be submitted on a CMS approved claim form.

UB 04 (Institutional) Claim Form

Helpful hints to avoid errors that cause delays when paper claims are submitted for processing.

  • When submitting paper claim, submit original claim form for processing.
  • A copy of the Medicare EOB (and TPL EOB if applicable) is required. Claims received without a Medicare EOB will not be processed and returned to the provider.

Helpful reminders to avoid errors and delays when submitting a paper claim. (see National Uniform Claim Committee (NUCC) instruction manual )

  • A copy of the Medicare EOB (and TPL EOB if applicable) is required. Claims received without a Medicare EOB will not be processed and returned to the provider.
  • Form locator 17 b – NPI Only/ Blank- Please do not report any Medicaid Provider Numbers and/or UPIN numbers.
  • Form locator 24 J – NPI Only/ Blank- Please do not report any Medicaid Provider Numbers and/or UPIN numbers.
  • Form Locator 32 – Service Facility Location
    • 32 a – Enter the NPI #.
    • 32 b – Enter the two digit qualifier identifying the non-NPI number followed by the ID number.
  • Form Locator 33 – Billing provider Info and phone number
    • 33 a – Enter NPI of the billing provider.
    • 33 b – Enter the two digit qualifier identifying the non – NPI number followed by the ID #.
  • NOTICE: This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal and State laws. Sample Form

Adjustment/Void Forms

Adjustment/Void Forms are for use when either changes to a paid claim are required or when it is necessary to void a paid claim PLEASE NOTE: Denied claims cannot be adjusted or voided.

Instructions on how to fill out an Adjustment/Void Form are located on the second page/back of the Adjustment Form

Adjustment Form for Medicare/Medicaid claims



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