Let’s not overcomplicate this. If you’ve ever looked at a patient’s Medicare claim and wondered, “Who handles the secondary payment?”, you’re asking the right question. That’s exactly where crossover claims come into play.
In this guide, we’ll unpack what a crossover claim really is, how it flows through the system, what makes it different from a regular secondary claim, and how billers (and patients) can make the process smoother and faster.
What Is a Crossover Claim in Medical Billing?
A crossover claim is a medical claim that’s automatically forwarded from Medicare to a secondary insurance payer—typically Medicaid or a private supplemental plan after Medicare has paid its share.
In plain terms:
👉 Medicare is the primary payer.
👉 The crossover mechanism sends the remaining balance to the secondary payer.
👉 You don’t have to submit it twice if the system works.
The idea is to reduce administrative burden for healthcare providers and ensure quicker payments from both payers without duplicate submissions.
Why Do Crossover Claims Matter?
Because time matters. So does accuracy. Without proper crossover handling, providers risk:
- Delays in secondary reimbursement
- Unpaid balances passed on to patients
- Unnecessary rework from billing staff
- Compliance risk for dual-eligible patients (Medicare + Medicaid)
Getting this wrong is a recipe for backlogs and denied revenue.
How Crossover Claims Work Step-by-Step
Here’s how the crossover claim process usually flows:
- Provider submits the claim to Medicare (the primary).
- Medicare processes the claim and pays its portion.
- Medicare identifies a secondary payer using Coordination of Benefits (COB) data.
- Claim is automatically “crossed over” to that payer electronically.
- Secondary payer processes the balance, then pays or denies accordingly.
- Remittance advice (ERA or EOB) reflects both payments, ideally matched in your billing system.
Now here’s the twist: it’s not always automatic.
Who Is Eligible for a Crossover Claim?
Crossover claims only work if:
- The patient has active Medicare Part B coverage
- There is a registered secondary payer on file with Medicare
- The provider is enrolled in the crossover program (CMS + payer-specific)
Patients who are dual-eligible (Medicare + Medicaid) are usually enrolled automatically. For others—like those with AARP Medigap or Blue Cross supplemental insurance—it depends on payer agreements.
Pro Tip: Use the Medicare Eligibility Tool (via clearinghouse or MAC portal) to confirm secondary crossover status.
Crossover Claim vs Secondary Claim: Key Differences
| Feature | Crossover Claim | Secondary Claim (Manual) |
|---|---|---|
| Submission Method | Auto-forwarded by Medicare | Manually submitted by provider |
| Who Sends the Claim? | CMS system | Provider’s billing staff |
| Common For | Medicare + Medicaid or Medigap | Commercial + secondary combinations |
| Error Rate | Lower (if set up properly) | Higher risk of human error |
| Processing Time | Often faster | Can be delayed by manual handling |
If the crossover doesn’t fire, you still have to submit a secondary claim manually.
How to File a Crossover Claim (or Fix It If It Fails)
Most of the time, you don’t file it—it files itself. But when it doesn’t work, here’s what to do:
🔹 Step 1: Check Eligibility
Confirm that the patient’s Medicare record has the secondary payer on file. If not, use the COB update process.
🔹 Step 2: Review the ERA
Does it show forwarding to a secondary payer? If not, you’ll need to manually submit to the secondary with the Medicare EOB attached.
🔹 Step 3: Contact the MAC or Medicare
If crossover is expected but not happening, check with your Medicare Administrative Contractor (MAC). They may need to update enrollment records.
🔹 Step 4: Resubmit Electronically or via Portal
Most Medicaid plans and commercial payers allow electronic secondaries with appropriate adjustment codes (CO‑45, PR‑1, etc.). Always attach the original EOB or remittance details.
Top Tips for Successful Crossover Claim Submission
- Enroll properly with all expected crossover payers via CMS.
- Keep your billing software updated with payer ID mappings.
- Verify COB data on every new Medicare patient.
- Use ERA matching tools in your clearinghouse to spot mismatches.
- Train staff to recognize when a crossover failed—and when to step in.
- Monitor crossover claim processing timeframes (usually 5–15 business days).
- Maintain a denied crossover claim workflow—don’t wait weeks to act.
Common Mistakes When Filing Crossover Claims
- Relying on auto-crossover without verifying it worked
- Submitting a duplicate secondary claim before checking remittance
- Skipping the Medicare EOB when filing a manual secondary
- Incorrect COB/insurance sequencing on the claim
- Forgetting to update patient insurance data every benefit year
These are preventable—but they happen daily in real-world billing departments.
How to Appeal a Denied Crossover Claim
Sometimes, a claim hits Medicare fine—but the secondary denies it for one of the following:
- Patient not eligible on the date of service
- Missing or mismatched primary EOB
- Non-covered services
- Timely filing exceeded
In those cases:
- Gather the Medicare EOB, claim copy, and any required attachments.
- Submit an appeal request through the secondary payer’s online portal or mail.
- Track it. Most appeals take 30–45 days, depending on the payer.
Alternatives to Crossover Claims
Sometimes crossover just won’t work. In that case, use:
- Manual secondary claim submission
- Clearinghouse resubmission tools
- Paper CMS-1500 with attached EOB
If a crossover payer repeatedly fails, consider disenrolling and re-enrolling or updating COB via the patient’s myMedicare.gov account or a phone call.
Benefits of Filing Crossover Claims Correctly
- Faster secondary payments
- Lower staff workload
- Fewer billing errors
- Cleaner audit trail
- Higher patient satisfaction (especially dual-eligibles)
In billing, clean is king. And nothing is cleaner than a crossover claim that works without human intervention.
Key Takeaways
- A Crossover Claim in medical billing is a Medicare-initiated process to forward claims to secondary insurers automatically.
- Providers must verify eligibility and payer setup to ensure proper handling.
- If auto-crossover fails, billers must step in and submit manually.
- Accurate COB data, system settings, and trained staff make all the difference.