Get Ms Medicaid Crossover Form

The Ms Medicaid Crossover Form is essential for submitting claims for services covered under Medicare Part C. This guide will provide clear instructions on how to fill out this form online, ensuring you can submit your claims efficiently and accurately.

Follow the steps to complete the Ms Medicaid Crossover Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the provider name and address in the designated field. Ensure that all details are accurate to prevent any delays.
3. Input your Medicaid provider number in section 2a and your NPI number in section 2b. In section 2c, fill in your taxonomy code.
4. Provide the recipient’s Medicaid ID number in field 4, followed by their name and address in section 3.
5. List the primary diagnosis in section 6 and input the service dates in section 7. Ensure to include both the start and end dates.
6. Enter the procedure code in section 8 and any applicable modifier in section 9.
7. Specify the service units in section 10 along with the total Medicare billed charges in section 11.
8. Fill in the amounts regarding Medicare's allowed amounts in section 12 and detail the amounts paid by Medicare in section 15.
9. Complete the fields for the Medicare deductible in section 16, co-insurance in section 17, and paid date in section 18.
10. If applicable, enter any third-party amounts in section 19, and include blood deductible amounts in section 14.
11. Finally, review your entries for accuracy. Once satisfied, you can save changes, download, print, or share the completed form.

Complete your Ms Medicaid Crossover Form online today for efficient claim processing.