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Crossover Only Provider Authorization Information

"Crossover Only" providers, by definition, must meet two required conditions. The first condition is that they are enrolled in Medicare and they are not enrolled in Medi-Cal. The second condition is that they have provided a service to a dual-eligible beneficiary and are seeking approval for reimbursement of that service.

Dual-eligible beneficiaries are those beneficiaries who are eligible for coverage by both Medicare (either Medicare Part A, Part B or both) and Medi-Cal. Typically, claims for services rendered to dual-eligible beneficiaries are first processed by Medicare and are then sent electronically to Medi-Cal. Medi-Cal’s payment system then reimburses the applicable cost-sharing amount of the remaining claim amount.

Effective October 2010, Medicare providers who sought to obtain authorization from Medi-Cal to submit claims for reimbursement of Medicare cost-sharing amounts were no longer asked to submit a complete application package. In accordance with 42 United States Code §1396a(a)(10)(E)(i), the California Department of Health Care Services developed the "Crossover Only Provider Form" (MC 0804), specific to Crossover Only providers seeking authorization to bill for services rendered to a dual-eligible beneficiary AND who DO NOT wish to enroll as a full Medi-Cal provider.

The completed MC 0804 form, along with a copy of the provider’s Medicare enrollment verification and Taxpayer Identification Number verification can be mailed to:

Department of Health Care Services

Provider Enrollment Division

MS 4704

P.O. Box 997412

Sacramento, CA 95899-7412

Last modified on: 7/3/2015 5:39 PM