New Pricing Methodology for Exhausted Medicare Part A Benefits on Crossover Claims

Effective April 29, 2018, the N.C. Division of Medical Assistance (DMA) will implement a modification to pricing of Medicare Part A crossover claims. The modifications will be reflected in NCTracks through the following areas:

  • Claims which indicate Medicare Part A institutional benefits have been exhausted prior to the inpatient stay shall be priced as straight Medicaid inpatient claims. The lesser of pricing logic will not be applicable to these claims.
  • The comparison of the estimated amount due to the net payable amount on medical institutional claims will be removed from pricing logic.

Occurrence code A3 indicates the last date for which benefits are available and after which no payment can be made by payer A. When the claim contains A3 with a date prior to the claim Statement From Date of Service then the new exhaust claim pricing logic will be applicable.

For claims meeting the exhaust claim pricing criteria noted above, the Medicare Part B paid amount will be subtracted from the Medicaid Allowed Amount. The exhaust claim pricing will not occur when there is no indication of a Medicare part B payment, or Medicare Part A is indicated with an allowed amount greater than $0. Other payer amounts submitted on the claim including Medicare Part C and Commercial Insurance will continue to be subject to lesser of pricing logic.

Providers can continue to submit estimated amount due on institutional claims but the comparison of the estimated amount due (currently indicated by A3, B3 and C3 values codes) to the net payable amount will no longer occur for medical institutional claims.

In addition, two new system edits are being implemented to prevent duplicate payment on institutional crossover claims. Edit 59130 will deny the current claim with Explanation of Benefits (EOB) codes 59130 - DUPLICATE. OUTPATIENT CROSSOVER OVERLAP WITH INPATIENT CLAIM. Edit 59140 will pay the current claim and reverse the previously paid claim in history with EOB 59140 - DUPLICATE. INPATIENT OVERLAP WITH OUTPATIENT CLAIM.

These changes will apply to all claims regardless of the dates of service. Once the exhaust pricing changes are implemented, previously adjudicated exhaust claims can be resubmitted. Previously paid claims (even if paid $0) should be voided and a new claim should be submitted indicating the occurrence code A3 Medicare part A exhaust date with Medicare part B payment. If your claim is outside of the initial 365 timely filing limit then follow the time limit override process described in the Provider Adjustment, Time Limit & Medicare Override Job Aid.

Updated clinical policy documents will be available on the N.C. Medicaid website. For more information on lower of logic pricing, refer to the  Secondary Claims page of the NCTracks provider portal.