REF

Mandatory Medicare (Section 4081) Crossover Indicator

Pos: 180	Max: 1
Detail - Optional
Loop: 2300	Elements: 2

Ref

Id

Element Name

Req

Type

Min/Max

Usage

REF01

128

Reference Identification Qualifier
Description: Code qualifying the Reference Identification

M

ID

2/3

Required

Code

Name

F5

Medicare Version Code

REF02

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Medicare Section 4081 Indicator
NSF Reference: DA0-30.0

C

AN

1/30

Required

Code

Name

N

Regular crossover (NSF Value 2)

Y

4081 (NSF Value 1)

1.

R0203 - At least one of REF02,REF03 is required

1.

REF04 contains data relating to the value cited in REF02.

Notes:

1. Required for Medicare COB crossover claims when Beneficiary Assignment for mandatory Medicare (Section 4081) claim applies. This segment is only completed by Medicare; providers do not use this segment.
2. If this segment is not used that means this situation does not apply.

Example:

REF*F5*N~