Get Ms Crossover Claim Form 2016-2025

This guide provides clear and comprehensive instructions for filling out the MS Crossover Claim Form online, ensuring accurate and efficient submission. Follow these steps to navigate the form with confidence and ensure compliance with the necessary requirements.

Follow the steps to complete the MS Crossover Claim Form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your provider name and address in the designated field to identify who is submitting the claim.
3. Input your 8-digit Medicaid provider number to establish your credentials.
4. Provide your 10-digit National Provider Identifier (NPI) number that will link your practice.
5. Fill in the taxonomy code if you are a subpart of a facility; this is important for billing purposes.
6. Enter the full name and address of the beneficiary receiving services in the appropriate fields.
7. Input the 9-digit Medicaid ID number assigned to the beneficiary to ensure accurate processing.
8. Provide the patient account or medical record number to facilitate tracking of services rendered.
9. Input up to four diagnosis codes related to the billing period, starting with the primary diagnosis.
10. Indicate the service dates (from and through) in MM/DD/CCYY format to reflect when services were provided.
11. For outpatient services, enter the HCPCS code, or for professional services, provide the appropriate CPT code.
12. Fill in the applicable National Drug Code (NDC) for services rendered where necessary.
13. Enter any applicable procedure modifiers to detail the services provided.
14. Input the number of units provided for each detail line in the appropriate field.
15. List the total billed charges to Medicare for each detail line accurately.
16. Enter the Medicare allowed amount payable for each service as determined by Medicare.
17. Detail any charges for non-covered services under Medicare if applicable.
18. Indicate the Medicare deductible amount to be paid by Medicaid.
19. Fill the total amount paid by Medicare on the claim for each detail line.
20. Sign the claim form to authorize submission; rubber stamp signatures are acceptable.
21. Enter the date when the claim was submitted to ensure accurate processing from MM/DD/CCYY format.
22. Once completed, save changes, download or print the form, and share as needed for submission.

Complete your MS Crossover Claim Form online today to ensure timely and accurate submissions.