Get Crossover Form Part A - Mississippi Division Of Medicaid - Medicaid Ms

The Crossover Form Part A is essential for submitting claims to the Mississippi Division of Medicaid. This guide will assist you in accurately completing the form online to ensure a smooth submission process.

Follow the steps to complete the Crossover Form Part A online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin with the 'Type of Bill' section. Indicate the appropriate type by selecting the relevant code for Medicare Part C.
3. In the 'Provider Name and Address' field, enter the full name and address of the service provider.
4. Fill in the 'Medicaid Provider Number' and 'NPI Number' in fields 3a and 3b, respectively, as required for identification purposes.
5. Complete the 'Taxonomy Code' in field 3c. This code categorizes the provider's specialty.
6. Enter the 'Recipient Name and Address' in the designated field, ensuring that the details match the individual receiving services.
7. Input the 'Recipient Medicaid ID' in field 5 and the 'Patient Account/Medical Record Number' in field 6 for tracking purposes.
8. Record the 'Date' of service in field 7 accurately.
9. Indicate the number of 'Covered Days' in field 11, reflecting the duration of services provided.
10. List the primary and secondary diagnoses in field 12. Include any additional diagnosis codes as necessary.
11. Provide financial details in the following fields: 'Total Medicare Deductible Amount' (16), 'Total Medicare Billed Charges' (13), 'Total Medicare Allowed Amount' (14), and others as relevant.
12. Ensure that the 'Provider Signature' is entered in field 25, confirming the accuracy of the information provided.
13. Lastly, fill in the 'Billing Date' in field 26 before finalizing your submission.
14. Review all entries for correctness. Users can then save changes, download, print, or share the completed form.

Complete the Crossover Form Part A online to streamline your Medicaid claims process.