Crossover Only Provider Authorization Information (Fee-for-Service Members Only)
"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 member and are seeking approval for reimbursement of that service.
Dual-eligible members are those members 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 members are first processed by Medicare and are then sent electronically to Medi-Cal Fee-for-Service (FFS). Medi-Cal’s FFS payment system then reimburses the applicable cost-sharing amount of the remaining claim amount.
For Medi-Cal fee-for-service members (not enrolled in a managed care plan), physicians may request to receive reimbursement as a “Crossover Only” provider through the DHCS PAVE Provider Portal.
Please note that Medi-Cal managed care plans have their own processes for obtaining physician information for cost sharing payments. Providers servicing managed care plan members should NOT submit “Crossover Only” provider forms through the DHCS PAVE Provider Portal. Instead, contact the respective managed care plan for assistance with crossover only provider payments.
