Provider Quick Tip

Crossover Claims – Ordering and Referring Providers

From the PA Dept. of Human Services

Federal law requires providers, who order, refer or prescribe a service or item submitted for payment to the PA Medical Assistance (MA) program, enroll in the MA program. This regulation extends to crossover claims submitted by both providers and Medicare carriers.

DHS has identified conflicting guidance given to providers by Medicare and MA in relation to the completion of the ordering and referring field segments within the 837 Professional file layout when identifying the ordering, referring or prescribing provider on the claim.

Until system changes are implemented, the Department has received approval from CMS to request, when applicable; providers submit claims with an enrolled ordering, referring or prescribing provider NPI in both the ordering and referring provider fields on all 837 professional claims submitted to Medicare and crossed over to MA for processing.

On the 837P transaction, ordering, referring or prescribing provider information can be submitted at the claim level and the service line level.

2310A   NM1         Referring Provider Name
2310A   NM109    Referring Provider Identifier

If the ordering, referring or prescribing provider information for a service line differs from what
was submitted in loop 2310A, then the service line referring provider information should be
submitted in the following loop:

2420F   NM1         Referring Provider Name
2420F   NM109    Referring Provider Identifier

Medical Assistance enrollment information can be found at the following website: http://www.dhs.pa.gov/provider/promise/enrollmentinformation/index.htm