To bill electronic claims for HCPCS codes with local carrier jurisdiction, contact your local Blue plan or their EDI administrator for billing instructions.

Michigan providers should include the following information:

Variable
ANSI 837 format
CMS-1500 (02/12) claims format
UB-04 claims format
Reserved for local use
Field 19 – Indicate if Part A skilled nursing facility benefits have been exhausted or if reporting a customized prosthetic device.
Signature
Field CLM06 of 2300 Loop – Provider signature on file must equal "Y" Field 31 – Signature of physician or supplier including degrees or credentials and date ("Signature on file" is not acceptable) Field 85 – Provider representative signature and date ("Signature on file" is not acceptable)
Facility source of payment Field SBR09 of 2000B Loop (MA) N/A
Field 50 – 1st position "C" for Medicare
Professional source of payment Field SBR09 of 2000B Loop (MB) N/A
N/A
Facility Payer ID Field NM109 of 2010BB Loop (00210) N/A
Field 50 – 2nd thru 6th position (00210)
Professional Payer ID Field NM109 of 2010BB Loop (00710) N/A
N/A

Michigan providers billing claims with regional carrier jurisdiction

Complete a provider authorization and register your national provider identifier with us. Use source of payment Medicare B DMERC as the source of payment when completing the provider authorization.

Variable ANSI 837 format CMS-1500 (02/12) claims format UB-04 claims format
Professional Payer ID Segment NM109 of 2010BB Loop (00710) – Report "MADME" (Payer ID) N/A N/A
CMN or other appropriate documentation Segment SBR09 of 2000B Loop – Report "MB" (Source of pay)