Every Medicare to Medicaid crossover claim is rejecting by Medicaid because the 2010AB Pay-to provider is being added to the crossover claim by Medicare prior to sending it to Medicaid. The inbound orginal claim from the provider to Medicare did not contain the Pay-to loop because it is known that FL Medicaid looks at this loop as if it is the Billing Provider if it is populated and this impacts the Medicaid NPI crosswalk. The usage rule says that the loop is only to be used if the Pay-to provider is a different entity. We take that to mean a different business entity, not necessarily a different address for the same entity as reported in 2010AA. CMS does not interpret the usage rule the same way and thus has instructed the MAC to populate the Pay-to loop from thier Provider database before sending the crossover claim to Medicaid. Which interpretation is correct? We don't think that the MAC should be adding data to the crossover claim that wasn't on the original claim..
In the 4010 X096A1 Implementation Guide the Pay to Provider is considered a different entity than the Billing Provider. The Pay to Provider is only required when it is a different entity than the Billing Provider. However, in 4010 it is permissible to send the Pay to Provider loop if the Billing Provider is the same entity as the Pay to Provider and the Pay to Provider address is different than that reported for the Billing Provider.