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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyNorth Dakota Medicaid Crossover Policy | OpenPayer
    Ask Trek AI about this page
    CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

    Crossover Claims

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    Governs submission, eligibility, documentation, reimbursement, and claim requirements for providers billing North Dakota Medicaid for members eligible for both Medicaid and Medicare, including Medicare Advantage, D-SNP, and Medicare Supplemental Plans.

    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyCrossover Claims
    Policy CodePolicy N/A
    Change TypeNew policyno material clinical, coverage, or coding change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit claims for members with Medicare coverage to Medicare before submitting them to ND Medicaid, and include Medicare payment information on the ND Medicaid claim.
    SourceLink
    POLICY UPDATE CHANGES

    The policy updates section states that a new policy was created in January 2026.

    180 daysOriginal claim timely filing
    7 yearsRecord retention
    NoneCrossover authorization
    Medicare firstMedicare submission order

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    Coverage and Crossover Claim Requirements

    General coverage requirements

    Covered when ALL of the following general requirements are met:

    ALL of the following

    • Provider is enrolled with ND Medicaid.
    • Services are medically necessary.
    • Member is eligible on the date of service.
    • An approved service authorization is obtained when applicable.

    Crossover claim requirements

    For a crossover claim, ALL of the following requirements apply:

    ALL of the following

    • Member is eligible for both Medicaid and Medicare.
    • Claim is submitted to Medicare before it is submitted to ND Medicaid.
    • Medicare payment information is included on the ND Medicaid claim.

    General crossover claim requirements

    For a member with Medicare coverage, ALL of the following requirements apply:

    ALL of the following

    • Member has Medicare coverage.
    • Claim is submitted to Medicare before it is submitted to ND Medicaid.
    • ND Medicaid receives the original Medicare crossover claim within 180 days from the date on the Medicare Explanation of Benefits (EOB).Within 180 days from the Medicare EOB date

      The time limit may be extended only for situations involving member or provider retroactive eligibility.

    Claim-type-specific crossover requirements

    Meet the requirements for the applicable claim type and primary Medicare policy:

    ONE of

    • ALL of the following

      • Professional claim, submitted using the HCFA 1500 or 837p format.
      • Medicare Supplemental (Extended) policy is primary.
      • Submit two EOBs; report Medicare payment, member responsibility, and all other claim adjustments at the line level; and use filing indicator MB on 837p transactions.

    • ALL of the following

      • Professional claim, submitted using the HCFA 1500 or 837p format.

    Coding, Filing, and Record Requirements

    Professional Claim Filing IndicatormixedCovered
    MBMedicare crossover claim filing indicator for professional 837p transactions
    Institutional Claim Filing IndicatormixedCovered
    MAMedicare crossover claim filing indicator for institutional claims; the document states it applies on 837p transactions
    Permitted Claim Submission Formatsmixed
    HCFA 1500Professional claim form
    837pHIPAA electronic professional claim format
    UB04Institutional claim form
    837iHIPAA electronic institutional claim format
    Record retention
    Record typeMedical and financial records supporting services provided and billed to ND Medicaid
    Minimum retentionAt least 7 years
    Retention period begins afterThe last date the claim was paid or denied
    Original Medicaid primary claim timely filing
    Claim typeOriginal Medicaid primary claim
    Filing deadlineWithin 180 days
    Deadline measured fromThe date of service
    Original Medicare crossover claim timely filing
    Claim typeOriginal Medicare crossover claim
    Filing deadlineWithin 180 days
    Deadline measured fromThe date on the Medicare Explanation of Benefits (EOB)
    Original Medicare crossover claim filing limit
    Filing limit180 days
    Claim typeOriginal Medicare crossover claim
    Filing limit measured fromThe date on the Medicare EOB
    Medicare Supplemental (Extended) EOB requirement
    Policy typeMedicare Supplemental (Extended) coverage is primary
    EOBs required2 EOBs
    Applies toProfessional and institutional claims
    Medicare Advantage Part C EOB requirement
    Policy typeMedicare Advantage Part C coverage is primary
    EOBs required1 EOB
    Applies toProfessional and institutional claims

    Provider Billing and Submission Actions

    Billing Rule

    Verify provider enrollment

    Ensure the billing and servicing provider NPIs are enrolled with ND Medicaid on the date of service. A locum tenens servicing provider must also be enrolled with ND Medicaid and listed on the claim form.

    Documentation Required

    Verify member eligibility

    Verify the member’s eligibility before providing services and ensure the member is eligible on the date of service.

    Prior Authorization

    Confirm service authorization requirements

    Services must be medically necessary and have an approved service authorization when applicable. No service authorization is required for crossover claims.

    Billing Rule

    Submit to Medicare first

    For a member with Medicare coverage, submit the claim to Medicare before submitting it to ND Medicaid. Include the Medicare payment information on the ND Medicaid claim.

    Documentation Required

    Maintain supporting records

    Maintain legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Retain the records for at least 7 years after the last date the claim was paid or denied.

    Billing Rule

    Submit to Medicare first

    Submit a claim for a member with Medicare coverage to Medicare before submitting it to ND Medicaid.

    Denial Risk

    Meet the crossover filing deadline

    ND Medicaid must receive the original Medicare crossover claim within 180 days from the date on the Medicare Explanation of Benefits (EOB). This time limit may be extended only for situations involving member or provider retroactive eligibility.

    Documentation Required

    Report Medicare payment information

    Include Medicare payment information on the ND Medicaid claim.

    Billing Rule

    Report professional claim amounts at line level

    For professional claims, report Medicare payment, member responsibility, and any other claim adjustments at the line level of each claim.

    Documentation Required

    Submit two EOBs for Supplemental coverage

    When a Medicare Supplemental (Extended) policy is primary, submit two EOBs with the professional claim.

    Documentation Required

    Submit one EOB for Medicare Advantage

    When a Medicare Advantage (Part C) policy is primary, submit one EOB with the professional claim.

    Billing Rule

    Use the professional crossover filing indicator

    Submit professional claims as Medicare crossovers using the correct claim filing indicator code MB on 837p transactions.

    Billing Rule

    Report outpatient institutional amounts at line level

    For outpatient institutional claims, report Medicare payment, member responsibility, and any other claim adjustments at the line level of each claim.

    Billing Rule

    Report inpatient institutional amounts at header level

    For inpatient institutional claims, report Medicare payment, member responsibility, and any other claim adjustments at the header of each claim.

    Documentation Required

    Submit two EOBs for institutional Supplemental coverage

    When a Medicare Supplemental (Extended) policy is primary, submit two EOBs with the institutional claim.

    Documentation Required

    Submit one EOB for institutional Medicare Advantage

    When a Medicare Advantage (Part C) policy is primary, submit one EOB with the institutional claim.

    Billing Rule

    Use the institutional crossover filing indicator

    Submit institutional claims as Medicare crossovers using the correct claim filing indicator code MA on 837p transactions.

    Key Terms and Coverage Categories

    Crossover claims
    Member eligibilityThe member is eligible for ND Medicaid and Medicare
    Included Medicare coverageMedicare Advantage and Dual Special Needs Plans (D-SNP)
    Also includedMedicare Supplemental Plans (Extended Plans)
    Dual eligible
    DefinitionA member eligible for both Medicaid and Medicare
    Primary insurerMedicare is the primary insurer
    Eligibility verificationProviders are responsible for verifying eligibility before providing services
    Qualified Medicare Beneficiaries (QMB)
    Part B premiumsMedicaid pays Part B premiums
    Part A premiumsMedicaid pays Part A premiums in some instances
    Medicare cost sharingMedicaid pays deductibles, coinsurance, and copayments for services and items Medicare covers
    Special Low-Income Medicare Beneficiaries (SLMB)
    Program categorySpecial Low-Income Medicare Beneficiaries (SLMB)
    Covered premiumMedicaid pays the Part B premium
    Coverage limitationPart B premium only
    Qualifying Individual (QI1)
    Program categoryQualifying Individual (QI1)
    Covered premiumMedicaid pays the Part B premium
    Eligibility limitationThese individuals cannot be eligible for Medicaid
    Client share (recipient liability)
    DefinitionMonthly amount a member must pay toward the cost of medical services
    Who paysThe member
    Payment timingPaid before Medicaid pays for services received
    Professional crossover claim
    Claim typeProfessional claim
    Primary coverageThe member's primary coverage is Medicare
    Submission requirementsUse the required Medicare crossover filing indicator and include Medicare payment information
    Institutional crossover claim
    Claim typeInstitutional claim
    Primary coverageThe member's primary coverage is Medicare
    Submission requirementsUse the required Medicare crossover filing indicator and include Medicare payment information
    Medicare Supplemental (Extended) policy
    Coverage identificationMedicare coverage identified as Extended or Supplemental coverage
    Claim designationThe policy is designated as primary for the claim
    Applicable claim typesProfessional and institutional claims
    Medicare Advantage (Part C) policy
    Coverage typeMedicare Advantage Part C coverage
    Claim designationThe policy is designated as primary for the claim
    Applicable claim typesProfessional and institutional claims
    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyCrossover Claims
    Policy CodePolicy N/A
    Change TypeNew policyno material clinical, coverage, or coding change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit claims for members with Medicare coverage to Medicare before submitting them to ND Medicaid, and include Medicare payment information on the ND Medicaid claim.
    SourceLink
    On This Page
    Coverage and Crossover Claim RequirementsCoding, Filing, and Record RequirementsProvider Billing and Submission ActionsKey Terms and Coverage Categories
    Medicare Advantage Part C policy is primary.
  1. Submit one EOB; report Medicare payment, member responsibility, and all other claim adjustments at the line level; and use filing indicator MB on 837p transactions.

  2. ALL of the following

    • Outpatient institutional claim, submitted using the UB04 or 837i format.
    • Report Medicare payment, member responsibility, and all other claim adjustments at the line level.

  3. ALL of the following

    • Inpatient institutional claim, submitted using the UB04 or 837i format.
    • Report Medicare payment, member responsibility, and all other claim adjustments at the claim header.

  4. ALL of the following

    • Institutional claim, submitted using the UB04 or 837i format.
    • Medicare Supplemental (Extended) policy is primary.
    • Submit two EOBs.

  5. ALL of the following

    • Institutional claim, submitted using the UB04 or 837i format.
    • Medicare Advantage Part C policy is primary.
    • Submit one EOB and use filing indicator MA on 837p transactions.