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 N/A Field 19 – Indicate if Part A skilled nursing facility benefits have been exhausted or if reporting a customized prosthetic device. N/A
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

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.

Michigan providers billing claims with regional carrier jurisdiction
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) N/A N/A