How to Fill Out and Submit the TMHP MRAN Crossover Claim Form

The TMHP MRAN crossover claim form is a paper template Texas Medicaid providers use to bill the state for unpaid cost-sharing on Medicare Advantage Plan (Part C) claims involving dual-eligible patients. To use it correctly, choose the template that matches your original claim type, copy every field directly from the Medicare Advantage Explanation of Benefits (EOB), and mail the completed template to TMHP within 95 days of the Medicare disposition date, together with the EOB and a completed CMS-1500 or UB-04.

When the MRAN Template Applies

Most Medicare claims for dual-eligible patients cross over to Texas Medicaid automatically through the federal Coordination of Benefits Agreement (COBA) program, which electronically transfers finalized claims from Medicare’s Benefits Coordination & Recovery Center to TMHP.¹ When that works, you wait for payment on the next Remittance and Status (R&S) Report and do nothing.

The MRAN process exists for claims that don’t cross over automatically. Medicare Advantage Plan claims frequently fall outside the COBA pipeline, so providers must file them on paper. TMHP publishes the MRAN templates specifically for these MAP crossover claims.²

One boundary matters up front. Traditional Medicare Part A and Part B crossover claims that fail to auto-cross use a different attachment: the Medicare Remittance Advice (RA) or Remittance Notice (RN) from the Medicare Administrative Contractor, not the MRAN template. TMHP states the MRAN templates “must only be used for MAP claims.”² For paper Part A or Part B crossovers, submit the Medicare RA printed through CMS-approved software (MREP) or a paper MRAN received directly from the Medicare Administrative Contractor.³

Choosing the Right Template

TMHP publishes three MRAN templates. Pick the one that corresponds to the claim form you originally billed to the Medicare Advantage plan:⁴

Claim Type 30 (Professional) for services originally billed on a CMS-1500 — physician office visits, outpatient professional services, durable medical equipment, and independent lab work.
Claim Type 31 (Outpatient Facility) for UB-04 (CMS-1450) outpatient facility claims — hospital outpatient departments, ambulatory surgical centers, and similar facility-based outpatient services.⁵
Claim Type 50 (Inpatient Hospital) for inpatient stays billed on a UB-04.

Each template’s fields are tailored to its claim type, so mismatched templates won’t align with TMHP’s adjudication.

What to Gather Before You Start

Every data point on the MRAN template must be transcribed directly from the MAP EOB. Have all of the following in hand before you begin:

The MAP Explanation of Benefits. This is the source document. TMHP requires that information on the template match the EOB exactly; any discrepancy causes a denial.⁶
A completed CMS-1500 or UB-04 to accompany the template.²
The billing provider’s NPI and the performing provider’s NPI. Texas Provider Identifiers (TPIs) were eliminated effective September 1, 2021. Providers who don’t deliver healthcare services and were never issued an NPI may use an Atypical Provider Identifier (API) in its place.⁷
The client’s nine-digit Medicaid number from the Medicaid identification form.⁸
The billing provider taxonomy code and benefit code, matching your TMHP enrollment record.
The patient’s Medicare Health Insurance Claim (HIC) number from the MAP EOB.
The Medicare Internal Control Number (ICN) assigned by the Medicare Advantage plan, also on the EOB.

Completing the Template

The Claim Type 30 professional template is the most commonly used and its layout is representative of the other two. It has three sections: header, detail lines, and totals. Every field except the Medicaid client number comes from the MAP EOB.²

Header

Check the “MAP (Medicare Part C)” box. Enter the billing provider NPI, taxonomy code, benefit code, and full address including ZIP+4. Then enter the client’s nine-digit Medicaid number, the Medicare paid date, the client’s first and last name as they appear on the EOB, the Medicare ICN, and the Medicare HIC number. Copy names and numbers character-for-character from the EOB.

Detail Lines

Each service line on the MAP EOB gets its own row. For every line, enter the performing provider taxonomy and NPI, the from and to dates of service in MM/DD/YYYY format, the two-digit place of service code, the units billed, the CPT code and any modifiers, the billed charges, the Medicare allowed amount, and the patient-responsibility amounts (deductible, coinsurance, and blood deductible). Then enter the amount the Medicare Advantage plan paid and the Medicare reason code that explains the adjustment. Reason codes are typically Claim Adjustment Reason Codes (CARCs); “PR-1,” for example, indicates a deductible amount applied to the claim.

Totals

Sum the detail lines and enter totals for charges, allowed amounts, deductibles, coinsurance, and paid amounts. These totals must match the corresponding totals on the MAP EOB. A math error flags the claim during TMHP’s automated edits.

Submitting the Claim

Paper crossover claims are mailed to TMHP’s claims processing center. Each envelope must contain three documents together: the completed MRAN template, a copy of the MAP EOB, and the completed CMS-1500 or UB-04.³ The mailing address is in the Texas Medicaid Provider Procedures Manual; confirm the current address on the TMHP website before mailing, since processing centers occasionally move.

Electronic submission is now an option. As of late 2024, acute care providers can submit MAP Part C crossover claims electronically as “New Day” claims.⁹ Electronic submission follows HIPAA-compliant ASC X12 837 transaction standards, and TMHP’s EDI resources cover setup. Paper filing remains available and unchanged.¹⁰ TexMedConnect, TMHP’s web portal, is used for eligibility checks, claim status, and R&S Reports rather than for submitting paper crossover claim templates.¹¹

The 95-Day Filing Deadline

Texas Medicaid enforces a strict 95-day filing window for crossover claims. The clock starts on the date of Medicare disposition, meaning the date the Medicare Advantage plan finalized payment or denial. TMHP must receive the complete paper package within those 95 days.¹² There is also an outer boundary: 42 CFR 447.45(d)(1) requires all Medicaid claims to be submitted within 365 days of the date of service, and nothing overrides that.

Late claims are denied outright, and prior authorization does not waive the 95-day rule.¹³ TMHP does not handle exceptions. If extraordinary circumstances prevented timely filing, the exception request goes to HHSC Claims Administrator Operations Management, which can consider the situation under the Texas Administrative Code.

Why Crossover Claims Get Denied

Most denials come from a short list of preventable errors:

Data mismatch with the EOB. TMHP’s system compares every field against the MAP EOB. A transposed digit in the ICN, a slightly different billed amount, or a name spelled differently than on the EOB triggers a denial. By submitting the template, the provider attests that the information matches the EOB exactly.⁵
Missing facility NPI. When Medicaid rules require a facility NPI and the original Medicare claim included facility-based services, omitting it on the crossover claim causes a denial.³
Wrong template type. Using the Claim Type 30 professional template for a UB-04 outpatient facility claim, or the reverse, will get the claim returned or denied.
Using the MAP template for Part A or Part B claims. The MRAN templates are only for Medicare Advantage crossovers; traditional Medicare crossovers use the Medicare contractor’s RA or RN.²
Missing NDC for physician-administered drugs. Outpatient facility claims involving Part B drugs need one-to-one reporting of a National Drug Code for each Part B drug HCPCS code, or the state Medicaid agency will likely deny.¹⁴
Filed after 95 days. TMHP has no discretion; the only path is an exception request to HHSC.
Incomplete submission package. Missing the MAP EOB or the CMS-1500/UB-04 form means the claim cannot be processed.

Tracking and Appealing

After submitting, watch the weekly R&S Report for payment, denial, or pending status. Online R&S Reports are posted as downloadable PDFs every Monday at 6:00 a.m. Central Time; accessing them requires a provider administrator account on the TMHP website. Electronic R&S (ER&S) is also available through the TMHP-EDI Gateway using TexMedConnect or third-party software.¹⁵

If a claim is denied, the R&S Report shows the denial reason code. To appeal, submit a copy of the R&S Report page showing the denial, circle the relevant claim, state the reason for the appeal, and attach supporting documentation. Incomplete claims that TMHP returns can be resubmitted as original claims if received within the original 95-day filing deadline; otherwise, the resubmission must arrive within 120 days of the R&S Report date.¹⁵ Keep a clean copy of every MAP EOB and original claim form in a dedicated file so corrections are simple later.

1
Centers for Medicare & Medicaid Services. Coordination of Benefits Agreement
2
Texas Medicaid & Healthcare Partnership. Crossover Professional Claim Type 30 TMHP Standardized MAP Remittance Advice Notice Template Instructions
3
Texas Medicaid and Healthcare Partnership. Texas Medicaid Provider Procedures Manual – Claims Filing
4
Texas Medicaid & Healthcare Partnership. Forms
5
Texas Medicaid & Healthcare Partnership. Crossover Outpatient Facility Claim Type 31 TMHP Standardized MAP Remittance Advice Notice Template Instructions
6
Texas Medicaid & Healthcare Partnership. Reminder for All Providers Enrolled in Medicare: Submitting Paper Crossover Claims to Texas Medicaid
7
Texas Medicaid & Healthcare Partnership. TPI Number Removed from Medicaid Prior Authorization Forms
8
Texas Health and Human Services. R-3300, Client/Individual Number
9
Texas Medicaid & Healthcare Partnership. Reminder: Acute Care Providers Can Submit MAP Crossover Claims Electronically
10
Texas Medicaid & Healthcare Partnership. Clarification to Electronic Submission Option for MAP Crossover Claims to Be Available December 9, 2024
11
Texas Medicaid & Healthcare Partnership. TexMedConnect
12
Cornell Law School. 1 Texas Administrative Code 354.1003 – Time Limits for Submitted Claims
13
Texas Medicaid and Healthcare Partnership. Texas Medicaid Provider Procedures Manual – Claims Filing
14
Centers for Medicare & Medicaid Services. Medicare Billing: CMS-1450 and 837I – Claims Crossover
15
Texas Medicaid & Healthcare Partnership. Remittance and Status (R&S) Reports