What Is a Crossover Claim and How Does the Process Work?

A crossover claim involves coordinating benefits between two distinct health insurance plans for a single healthcare service. This process ensures that when an individual has coverage from more than one insurer, the financial responsibility for medical costs is appropriately distributed. The system navigates the complexities of multiple payers to determine which plan pays first and how remaining balances are handled.

Defining Crossover Claims

A crossover claim specifically refers to a healthcare claim processed by two different payers, where the information is automatically transmitted from the first payer to the second. This arrangement occurs when a patient holds more than one health insurance policy. The first insurer to pay is known as the “primary payer,” which processes the claim first according to its own benefits and rules.

Following the primary payer’s determination, any remaining balance or unapplied amount is then forwarded to the “secondary payer.” The secondary payer reviews the claim and the primary payer’s explanation of benefits (EOB) to determine if it will cover additional costs, such as deductibles, copayments, or coinsurance, up to its policy limits.

The Crossover Claim Process

The handling of a crossover claim begins when a healthcare provider submits the claim directly to the patient’s primary insurance payer. The primary payer then processes this claim, applying the patient’s deductible, copayment, or coinsurance amounts, and pays its portion of the allowed charges.

After the primary payer processes the claim, it generates an Explanation of Benefits (EOB) document. For a crossover claim, this EOB, along with the original claim information, is electronically transmitted to the secondary payer. This automatic forwarding eliminates the need for manual resubmission by the provider or patient. The secondary payer then reviews the primary payer’s payment and the remaining balance, determining its own payment responsibility based on its policy terms. Patients receive an EOB from both payers, detailing how each insurer contributed to the payment of their medical services.

Typical Crossover Claim Scenarios

Crossover claims frequently arise in situations where individuals qualify for multiple types of health coverage. A common example involves beneficiaries who have Medicare as their primary payer and Medicaid as their secondary payer, often termed “Medi-Medi” claims. In these instances, Medicare first processes and pays its share of the approved medical charges, and then the claim automatically crosses over to Medicaid, which often covers the remaining deductibles, coinsurance, and copayments that Medicare does not pay, within its own guidelines.

Another prevalent scenario involves Medicare as the primary payer and a commercial (private) insurance plan as the secondary payer. This typically occurs when an individual is eligible for Medicare, perhaps due to age or disability, but also maintains employer-sponsored health coverage, a retiree health plan, or a private Medicare supplement plan. Medicare will pay first, and the commercial plan will then evaluate the remaining balance, potentially covering additional costs based on its specific policy terms. These arrangements help reduce out-of-pocket expenses for individuals with dual coverage.