Medicare Crossover
You will need Adobe® Reader® to view PDF documents.
Click the button above to download a free copy of Adobe Reader.
Examples of Medicare Crossover Paper Claims
UB-04 Institutional Claim Forms
| Ex. # | Title | Last Modified |
|---|---|---|
| 1 | Inpatient Billing - Medicare Deductible and Coinsurance | 07/16/2008 |
| 2 | Inpatient Billing - Third-Party Insurance with Medicare Deductible and Coinsurance | 07/16/2008 |
| 3 | Inpatient Billing - Medicare as Primary and Third-Party as Secondary | 07/16/2008 |
| 4 | Outpatient Billing - Medicare Coinsurance Only | 07/16/2008 |
| 5 | Outpatient Billing - Medicare Deductible Only | 07/16/2008 |
| 6 | Outpatient Billing - Medicare Deductible and Coinsurance | 07/16/2008 |
CMS-1500 Professional Claim Forms
| Ex. # | Title | Last Modified |
|---|---|---|
| 7-9 | Three examples: Deductible and Coinsurance with Third-Party Liability, Coinsurance only, Deductible only | 11/29/2010 |
| 11-13 | Three Anesthesia examples: Deductible and Coinsurance, Coinsurance only, Deductible only | 11/29/2010 |