Air ambulance services must be billed based on pickup ZIP code

We’d like to inform our ambulance providers who offer air ambulance services about an important change. Effective Aug. 1, 2015, claims for air ambulance services must be filed with the Blue plan in the area where the point of pickup ZIP code is located. This applies to all Blue Cross Blue Shield of Michigan and Blue Care Network business.

For example, if the point of pickup ZIP code is in Michigan, you would file the claim with Blue Cross Blue Shield of Michigan. If the point of pickup ZIP code is in Ohio, you would file with the local Blue plan in Ohio.

To help you file, see the guidelines below.

For air ambulance services:

• CMS 1500 form: Include the five-digit zip code of the point of pickup in Box 23

• CMS 1450 (UB-04): If air ambulance service is not included with local hospital charges, include Value Code A0 in FL 39-41and the five-digit ZIP code of the location where the beneficiary was placed on board the ambulance in the related value amount field for FL39

• 837 electronic claims:
• Professional: Report all information in the entire Loop 2310E, including the point of pickup ZIP code.
• Facility: Report Value Code A0 in Loop 2300, HI Segment with a BE qualifier and the five-digit point of pickup ZIP code as the value amount.

Air ambulance claims submitted to the wrong plan will be rejected.

If possible, we encourage you to verify member eligibility and benefits by contacting the phone number on the back of the member’s ID card. For more information be sure to check the provider manuals or contact your provider consultant.