Use standard Medicare claim formats

• Electronic submitters: ANSI 837
• Billers submitting paper claims for professional services: CMS-1500 (08/05)
• Billers submitting paper claims for services by facilities and institutions: UB-04

Apply Original Medicare coding rules

• Paper claims — use your national provider identifier and federal tax ID as appropriate.
• Electronic submitters — use NPI only.
• Quantify facility services by revenue code categories, or, if reporting HCPCS codes, the number of units equal to the number of times the service or procedure is being reported.
• Use Medicare CPT codes and defined modifiers.
• Bill diagnosis codes to the highest level of specificity.
• Include physician's or supplier's signature. Include date, degrees or credentials. "Signature on file" is not acceptable.
• Use CMS-approved HCPCS codes modifiers.

Some services require a Certificate of Medical Necessity, a DME information form, a prescription or other documentation with the first-month supply claim, first-month rental equipment claim, or a claim for a one-time equipment purchase. We will deny claims that require, but do not include, appropriate documentation.

CMS Form	Type of Form	Service Description
CMS-484	CMN	Oxygen
CMS-846	CMN	Pneumatic compression devices
CMS-847	CMN	Osteogenesis stimulators
CMS-848	CMN	Transcutaneous electrical nerve stimulators
CMS-849	CMN	Seat lift mechanisms
CMS-854	CMN	Section C continuation form
CMS-10125	DIF	External infusion pumps
CMS-10126	DIF	Enteral and parenteral nutrition

CMS documentation forms

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 (08/05) 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 their 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 (08/05) 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)

• Remember to send DME/P&O and medical supply claims correctly based the carrier jurisdiction.
• Submit claims within 15-27 months of the date of service. Otherwise, we cannot pay for the service. You cannot charge a patient if you did not submit the claim to us.
• BCBSM or your local Blue plan will send you the remittance advice.
• BCBSM or your local Blue plan will reimburse you.